George H Kirby

Albert M Barrett

Adolf Meyer

Keywords: Adolf Meyer, dementia praecox, Elmer Er nst Southard, psychiatric nomenclature, schizophrenia

the Har vard neuropathologist Elmer Ernst Southard (1876-1920) presented a paper in which he outlined his reasons for dropping the term 'dementia praecox' in favour of a competing diagnostic concept and term, 'schizophrenia'. Southard's criticisms reflected the opinion of many US psychiatrists at that time, leading to the replacement of Emil Kraepelin's dementia praecox by Eugen Bleuler's schizophrenia in US psychiatry by the mid-1920s. The text of Southard's lecture is published here for the first time.

Introduction: from dementia praecox to schizophrenia

The year 1918 marked the beginning of a new era in US psychiatry. In that year the fi nal draft of a uniform classifi cation system for collecting statistics on mental diseases in US institutions was approved and published by the American Medico-Psychological Association (hereafter AMPA) and the National Committee for Mental Hygiene (hereafter NCMH). The Statistical Manual for the Use of Institutions for the Insane (AMPA and NCMH, 1918) was the fi rst formal diagnostic manual adopted for widespread use in the USA. State hospitals and other psychiatric institutions such as the various psychopathic hospitals were directed to collect statistics on their patients and submit them at the end of their fi scal year to the Bureau of Statistics of the National Committee for Mental Hygiene. By 1921 most institutions were doing so, and for the fi rst time in the USA comparative data were available for all psychiatric institutions (see Grob, 1985: 32). The Manual provided psychiatrists with a menu of 21 general categories of mental diseases and one for 'Not Insane'. A special Committee on Statistics of the AMPA had been debating the classifi cation structure and nomenclature of this document since a meeting in Niagara Falls in 1913, approving the fi rst complete draft on 29 May 1917 at the 73rd annual meeting of the AMPA in New York City and its fi nal draft at a meeting of the committee in New York City on 7 February 1918.

From the outset the issues of classifi cation and nomenclature had been contentious. The single most infl uential psychiatrist in the USA at that time, the Swiss émigré Adolf Meyer (1866Meyer ( -1950) ) of the Henry Phipps Clinic of Johns Hopkins Medical School, opposed both the need for a formal classifi cation system and the codifi cation of nomenclature for mental diseases. His arguments were twofold: fi rst, that too little was known about the 'facts' of mental diseases for psychiatrists even to begin such a project, and second, that the formal adoption of a national classifi cation scheme for mental diseases would reify certain diagnostic terms, making it diffi cult to modify or reverse their use as knowledge about these conditions progressed. History would prove he was correct on both counts.

Dementia praecox had been proposed as one of the 21 categories of mental diseases. Meyer himself had imported the German psychiatric term into the USA. He fi rst applied the diagnosis at the Worcester Lunatic Hospital in Massachusetts in the autumn of 1896 soon after visiting Emil Kraepelin (1856Kraepelin ( -1926) ) in Heidelberg in the spring. By 1900 dementia praecox had become an issue of discussion by US alienists and neurologists at conferences and in medical journals [START_REF] Noll | The American reaction to dementia praecox[END_REF]. But between the AMPA annual meeting in May 1917 -just one month after the USA declared war against Germany -and the approval of the fi nal draft of the Manual in February 1918, there was a ground swell of support for the adoption of an alternative diagnostic term proposed by the Swiss psychiatrist Eugen Bleuler : schizophrenia. How much of the timing of this shift in opinion can be attributed to genuine clinical concerns and how much to the visceral anti-German sentiment among the members of the AMPA remains an open question. Certainly many members of the AMPA, especially Meyer, knew of Kraepelin's strong and vocal support for the legitimacy of Germany's political aims and war efforts. Meyer, who at this time in his life identifi ed himself fi rst as American and second as Swiss, chastised his colleagues in the AMPA at the conclusion of his presentation at the May 1917 meeting by saying it was a 'distressing surprise' that 'our own committee on statistical classification should at this late hour have sworn allegiance to the German dogma' (Meyer, 1917(Meyer, -1918: 168): 168). The fi nal published draft of the Manual refl ected both the fundamental disagreement about the clinical contours of dementia praecox and the fact that a competing term and vision of insanity were already in use in the USA. According to the Manual's brief description of 'Dementia Praecox' (AMPA and NCMH, 1918: 24):

This group cannot be satisfactorily defi ned at the present time as there are still too many points at issue as to what constitute the essential clinical features of dementia praecox. A large majority of the cases which should go into this group may, however, be recognized without special diffi culty, although there is an important smaller group of doubtful, atypical allied or transitional cases which from the standpoint of symptoms or prognosis occupy an uncertain clinical position.

Cases formerly classifi ed as allied to dementia praecox should be placed here rather than in the undiagnosed group. The term 'schizophrenia' is now used by many writers instead of dementia praecox.

Even after the publication of the fi rst edition of the Manual, the debate about dementia praecox versus schizophrenia still continued to occupy the most prominent fi gures in the US psychiatric community. Perhaps the most energetic catalyst for pressing this issue after the publication of the Manual was Elmer Ernest Southard (1876Southard ( -1920)), Bullard Professor of Neuropathology at Harvard Medical School (since 1909), Pathologist to the Massachusetts Commission on Mental Diseases (since 1912), Director of the Boston Psychopathic Hospital (since 1912), and by all accounts one of the most remarkable physicians in early twentieth-century US medicine; see Fig. 1 E. E. Southard (his intimates called him 'Ernie') was remembered by his contemporaries in metaphors more appropriate for a comet than a man. Perhaps this has to do with his sudden death at the age of 43 on 8 February 1920 from infl uenza that quickly transformed into fatal pneumonia. His biographer, former colleague and lifelong friend, the bacteriologist Frederick Gay (1874Gay ( -1939)), collected numerous memoirs from Southard's associates attesting to his boundless energy, sanguine temperament, humour, love of wordplay, scintillating intellect, power to inspire others and polymathic creativity [START_REF] Gay | The Open Mind: Elmer Ernest Southard, 1876-1920[END_REF]. He exhibited an 'Edisonian habit of sleeplessness', often arriving at work in the morning after playing chess all night, sometimes competing in contests of 'blind chess' in which his extraordinary powers of visualization and spatial cognition enabled him to play as many as six games simultaneously (Gay, 1938: 52-3). L. Vernon Briggs, an associate of Southard who would later write a history of the Boston Psychopathic Hospital, claimed that:

He himself said that most people fell within one of the classifi cations of mental disease, and he felt himself to be of the manic-depressive type. We seldom saw the depressive side of him though it was undoubtedly there; ordinarily he appeared carried away with enthusiasm about his latest interest -and everything worthwhile interested him (Gay, 1938: 263-4) Gay, whose biography of Southard is occasionally spiced with details not often found in such medical hagiographies, reported that his beloved FIG. 1. E. E. Southard in July 1919, aged 43 (source: Canavan, 1925) friend 'had no hesitation in classifying himself temperamentally … as actually hypomanic' (Gay, 1938: 263). 'He was forever "starting things," and he has been accused of not fi nishing them', Gay (1938: 242) observed, and the wide range of topics explored in his neuropathological studies, his writings on psychiatric classifi cation and nomenclature, psychiatric social work and mental hygiene attest to his wandering intellectual interests. But the fl ashes of brilliance in the three books and 179 published articles he left behind never compensated for one basic fact: today he is not remembered for any single medical or scientifi c breakthrough. However, it is clear from the testimonies of his colleagues and from his literary remains that he believed his greatest accomplishment might very well come from his future work on dementia praecox. Dementia praecox was the subject of 13 publications by Southard between 1908 and 1919, 10 of which were either reports of neuropathological studies of the brains of persons with dementia praecox or comparisons with the brains of persons with manic-depressive illness and normal controls [START_REF] Southard | A study of the dementia praecox group in light of certain cases showing anomalies or scleroses in particular brain regions[END_REF], 1913, 1914a, 1914b, 1914[START_REF] Southard | Advantages of a pathological classifi cation of nerve cells, with remarks on tissue decomplication as shown in the cerebral and cerebellar cortex[END_REF][START_REF] Southard | Advantages of a pathological classifi cation of nerve cells, with remarks on tissue decomplication as shown in the cerebral and cerebellar cortex[END_REF][START_REF] Southard | Dissociation of parenchymatous (neuronic) and interstitial (neuroglia) changes in the brains of certain psychopathic subjects, especially in dementia praecox[END_REF], 1919a[START_REF] Southard | The stratigraphical analysis of fi ner cortex changes in certain normal-looking brains in dementia praecox[END_REF], 1918). Poking fun at the schism in psychiatry between the 'mind-twist men' and the 'brain-spot men', and denying a strictly functional or a strictly organic interpretation of mental disease, Southard believed that science was best served by investigating dementia praecox from complementary angles of approach: both the clinical and the anatomical, both the psychopathological and neuropathological (Southard, 1914c). As for Southard himself, his position on the mind-body problem was always uppermost in his philosophical mind: 'I wish however to say personally neither parallelism nor interactionism seems to me safe ground and that some kind of identity hypothesis for all the operations concerned would be better consonant with my views' (Southard, 1914c: 129). When Southard began his neuropathological study of dementia praecox in 1910, 'it seemed to [him] that very probably the brains of dementia praecox patients would be found to be normal' (Southard, 1914c: 121). He was surprised to fi nd evidence to the contrary. As he expanded his series of dementia praecox subjects, he continued to fi nd diffuse structural abnormalities in most cases, but many fewer in cases of manic-depressive insanity or normal controls. He judiciously did not over-interpret his fi ndings to argue that dementia praecox was defi nitively found to be an organic disease in aetiology, nor did he claim the discovery of a defi nitive characteristic cellular pathology for it. Southard professed the need to keep an open mind about the matter, and often argued that his fi ndings were provisional. The cognitive categories that guided his personal approach to understanding mental disease were structure and function, and he understood the two to be intertwined: 'Structure is in the main the spatial aspect of facts and events, function in the main the temporal aspect of the same facts' (Gay, 1938: 200). But according to one colleague who knew him well, 'Southard's conclusion regarding dementia praecox was that it is in some sense structural. Manic depressive he regarded as more likely a metabolic disturbance' (Gay, 1938: 246).

Southard was regarded as the leading neuropathologist of his generation in the USA, and his fi ndings were diffi cult to ignore, even by the most ardent psychogenicists. His own colleagues marvelled at the way he could glance at a fresh human brain and instantly 'see' its uniqueness in a manner similar to the way in which he could glance at a chess board and 'see' the possibilities inherent in its implicate structure. 'While to most of us brains are as alike as Chinamen, he seemed to possess something of the "photographic mind" which instantly detects slight peculiarities', reported one colleague.

I still retain a vivid memory of seeing him at his task of examining brains and of noting how unhesitatingly, in the course of the rapid inspection, he pointed out small variations, and how confi dently, as he ran his fi ngertips over the fresh surface, he dictated his impression of differences in resistance. (Gay, 1938: 228) Southard's acute sensitivity to neural tissue in an era of technological simplicity led to an observation and an interpretation about the neuropathology in dementia praecox brains that has been supported by modern neuropathological research on schizophrenia: almost every part of the brain in persons with schizophrenia has been found to have abnormalities in one study or another, and this may be evidence in support of an embryonic or 'neurodevelopmental' origin for the disorder [START_REF] Harrison | The neuropathology of schizophrenia: A critical review of the data and their interpretation[END_REF]).

Southard's suggestions for improving classifi cation in psychiatry were among his least infl uential contributions. His plea for a 'pragmatic psychiatry' based on a process of 'diagnosis by exclusion' through a 'pragmatic sequence of consideration' of eleven groups of mental disorders, including one termed the 'Schizophrenoses' (Southard, 1919b), was never adopted in US psychiatry. In an exchange of letters with Meyer in mid-December 1918 (reproduced in Grob, 1985: 28-9), Southard was unsure about the propriety of using his position as president of the AMPA to induce 'a small controversy at the next meeting of the Association' concerning the issues of classifi cation and nomenclature, but Meyer signalled his rejection of such public engagement. Southard attempted to negotiate common ground with Meyer and get him to agree to a need for broad classifi cation groups, although he regarded the 'nomenclature question' as 'subordinate'. Southard wrote on 11 December 1918, 'The statistical committee could give as synonyms such names as it chose to regard as synonyms for the leading names of its list. Let any psychiatrist, however, use what name he chooses.' He thus gave Meyer the promise of allowing psychiatrists to use Meyerian terms such as 'reaction-types' if they preferred, but within the general outlines of an agreed classifi cation grouping. Meyer would never give ground. Aware that his proposal for his classifi cation groupings would fi nd stiff resistance among psychiatrists, Southard opted instead to fi ght a battle that he might win: convincing his colleagues to adopt the term schizophrenia in place of dementia praecox.

On 20 February 1919 Southard delivered a lecture to the Boston Society of Psychiatry and Neurology on 'Non-Dementia Non-Praecox' which is the basis of the previously unpublished Classic Text reproduced below. 1 It is his clearest statement on the unsuitability of Kraepelin's term and concept of dementia praecox and his argument for the adoption of Bleuler's schizophrenia as a more palatable replacement. At the time, Southard was President of the AMPA, and this fact added weight to his argument for a change in nomenclature. The manuscript, and its supporting documents (also reproduced here for the fi rst time), remain among the E. E. Southard papers at the Center for the History of Medicine at the Francis A. Countway Library of Medicine, Harvard Medical School. Southard prepared the text of his lecture in a typescript form that was intended for publication, but like so many other projects in his life, he never completed the task. In less than a year he would be dead.

In a post-mortem examination of Southard's brain (and its comparison with those of his father, who had died in 1910, and his mother who had died in 1921), his close friend and collaborator in his neuropathological studies, Myrtelle M. Canavan (1879Canavan ( -1953)), recorded a rather cryptic summary of Southard's last days:

The last year of his life was fraught with singular diffi culties producing considerable mental discomfort, resulting in an edgy spirit of unrest. To compensate he worked feverishly at writing, skimmed the library for the stimulation of novel facts, poured over word studies, and became worried over facts he had hitherto neglected as unimportant. In the fall of 1919 he visited the Georgia State Sanitarium at Midgeville and came home talking much of religion, of God, and of the simplicity of Blacks. At times he said, 'I shall not live long, I must hurry; I must get lots of others busy.' (Canavan, 1925: 12-13) Two months before his death, a medical examination from an 'endocrinological standpoint' was conducted in December 1919, andCanavan (1925: 13) interpreted Southard's escalating diffi culties as consistent with 'a persistent thymic state'. Thus, a metabolic diagnosis, not a psychiatric one, was left to history by one of his most devoted disciples. Around the time of Christmas 1919, according to Canavan (1925: 14), he spoke of one of his many great unfi nished tasks as 'his hope to put together all his ideas on Dementia Praecox for review and refutation of the criticisms of his 1910 studies on the subject.' This was not to be.

The archival material reproduced below includes Southard's manuscript for 'Non-Dementia Non-Praecox' and a small collection of materials that Southard apparently used when preparing his text: the full text of a letter from George H. Kirby (1875Kirby ( -1935)), and excerpts from letters from Albert M. Barrett (1871Barrett ( -1936)), Adolf Meyer (1866-1950) and August Hoch (1868-1919). Not included here (for reasons of space) is the text of a short summary and commentary by Southard on the views of Kraepelin concerning dementia praecox as presented in the 8th edition of his Psychiatrie (Kraepelin, 1913). Southard's most interesting observation about this edition is that Kraepelin renamed an illustration (Figure 154) which had also appeared in the 7th edition: he changed his description of the group of patients in the photo from 'dementia praecox patients' to 'schizophrenics'. Southard saw this as evidence of Kraepelin's acceptance of Bleuler's term, schizophrenia. In the English translation of this section, Figure 154 is renumbered Figure 3 and the photo is described as a 'group of schizophrenic patients' (Kraepelin, 1919: 38).

Southard makes several key points in his paper. First, that the neuropathological evidence is not pathognomonic for an actual 'entity' that could be named dementia praecox or schizophrenia. Second, that Bleuler's dissociative metaphor for schizophrenia is a better fi t for what Southard calls the 'psycholytic' nature of the phenomena that would be placed in this broad classifi cation group. Third, Meyer's preferred nomenclature of 'reactiontypes' or 'reaction-complexes' would be equally welcome in a classifi cation group that would include the alternative terms of dementia praecox and schizophrenia (and as such, Southard's remarks in this paper are a direct rejoinder to Meyer's AMPA address). Fourth, a classifi cation project aimed at synthesis (in other words, accepting a classifi cation group large enough to contain the concepts, if not the terms, of Meyer, Kraepelin and Bleuler) is consistent with Kraepelin's own grand synthesis of hebephrenia, catatonia and paranoia into dementia praecox, and any idea that Kraepelin 'created' a new entity is wrong. Fifth, the term dementia praecox itself is 'horrible' and gives the wrong impression about prognosis. Sixth, schizophrenia is a term from which adjectives can easily be formed (e.g., 'schizophrenic'), whereas such word forms cannot be derived from dementia praecox. And seventh, by February 1919 Kraepelin himself had given up his original 1899 concept of dementia praecox, multiplying the number of forms and relabelling some patients with Bleuler's suggested term, schizophrenia.

A brief note summarizing Southard's presentation to the 'regular meeting' of the Boston Society of Psychiatry and Neurology presided over by Dr George A. Waterman on 20 February 1919 appeared in the Journal of Nervous and Mental Disease (Southard, 1919c):

Dr. E. E. Southard spoke in regard to the unsuitableness of the term 'dementia praecox' furnished by Kraepelin, upon the badness of which term all are agreed. Some international committee on psychiatric terminology should be formed to select desirable psychiatrical terms.

Neither dementia nor praecox are indispensable features of what is called dementia praecox. The use of the term brings unhappiness to patients and much wrong results from its use. Catatonia was fi rst described in 1858. In 1896 Kraepelin used the term dementia praecox to include several types of mental disease. In 1913 he evolved thirteen types, containing nine types of dementia praecox and four of paraphrenia, and designated these thirteen types as endogenous deterioration. Bleuler later suggested that schizophrenia should be used instead of the undesirable term dementia praecox. This conveys the idea most important to this disease, the splitting of the personality, and it forms a good basis for various derivations. It does not commit one to any one notion of the mechanism involved nor of the nature of the process.

Dr. E. S. Abbott said that although the term was undesirable still many cases do reach dementia. Errors in diagnosis tended rather to create caution than to the necessity of eliminating a term. There should be clearer defi nition of symptoms. Science he believed develops by delineation not by substituting terms. Dementia praecox has a wider signifi cance than schizophrenia therefore there is no advantage in the latter as a substitute for the former. There should be a term separating those who dement from those who do not. There mere diagnosis is a secondary matter however in comparison with the treatment.

In the text of his 'Non-Dementia Non-Praecox' manuscript, Southard quotes from Meyer's May 1917 AMPA address, published as 'The aims and meaning of psychiatric diagnosis' (Meyer, 1917(Meyer, -1918) ) and also relies on the historical information concerning the evolution of the term and concept of dementia praecox from Morel, Hecker and Kahlbaum contained in a volume by Constance Pascal (1877-1937), La Démence précoce:Étude psychologique médicale et médico-légale (1911). Pascal (1911: 6) is also the source of Southard's observation that Kraepelin's contribution was one of synthesis and not the creation of an entirely new entity. It should be noted that Pascal's interpretation of dementia praecox as a disease caused by autointoxication (Pascal, 1911: 13, 240-8), which follows that of Kraepelin (see [START_REF] Noll | Kraepelin's 'lost biological psychiatry'? Autointoxication, organotherapy and surgery for dementia praecox[END_REF], is not mentioned by Southard, who found such an aetiology unlikely.

In late 1918, in order to prepare for his lecture and its planned publication, Southard wrote to several psychiatrist colleagues and surveyed them on the comparative suitability of dementia praecox and schizophrenia for the new American nomenclature in the Manual. Only the full letter of George H. Kirby, the Director of the Psychiatric Institute of the New York State Hospitals on Ward's Island, survives in full. He was not happy with either term, or how they are applied in practice. The remarks of Meyer, Barrett and Hoch are excerpted by Southard but the original letters are not to be found in Southard's papers. Meyer wished to see the term schizophrenia 'eliminated', but by May 1921 he was using the term interchangeably with dementia praecox in public presentations and publications (Meyer, 1921(Meyer, -1922)). Hoch, who played a key supporting role in forming the fi rst draft of the new uniform classifi cation system, cogently listed the reasons why dementia praecox was an unsuitable term, but was lukewarm to replacing it with schizophrenia. Barrett, who chaired the Committee on Statistics when the fi nal draft was approved in February 1918, was the only respondent to Southard who was unequivocal in his support of adopting schizophrenia and dropping dementia praecox.

The documents from the Nachlaß of E. E. Southard that are reproduced below provide a unique window into a critical moment in the history of psychiatry.

Note

1. Although Southard's text has never been published in full, Elizabeth Lunbeck (1994: 372) refers to the manuscript in the endnotes to her book on the Boston Psychopathic Hospital. I wish to thank the Harvard Medical Library in the Francis A. Countway Library of Medicine in Boston, Massachusetts, for permission to cite and publish these typescripts in the E.E. A proposal to excise from our psychiatric vocabulary the term Dementia Praecox will, I think, secure strong American support. As the American vocabulary of mental diseases is just now fast stiffening into a form that, for better or worse, must serve our purposes of mental hygiene for another quarter of a century, I believe we ought to hasten the extirpation, if not of all inaccurate terms, of all terms that are both inaccurate and dangerously misleading. We ought to begin our verbal surgery upon terms that not only offend by being logically inaccurate and block scientifi c progress by misleading the medical profession, but also are likely positively to injure the prognosis of many psychopathic cases.

The statistical committee of the American Medico-Psychological Association specifi cally allows us the use of the term Schizophrenia in place of Dementia Praecox -a proper concession to the increasing local and general usage of this far more exact and less misleading term, proposed by the eminent Swiss psychiatrist, Bleuler, for Kraepelin's term Dementia Praecox. As I write, the public history of the term Dementia Praecox in Kraepelin's sense is not twenty years old, dating from the issue of Kraepelin's edition of Psychiatrie in 1899. Bleuler's suggestion is 8 years old, if we date from his lucid volume Schizoiphrenie in Aschaffenburg's Handbuch, published in 1911. It is probably safe to say that neither of these terms is case-hardened enough to last say a century of further progress in psychiatry. Neither term has the look of age and respectability that say the terms General Paresis, Delirium Tremens, Senile Dementia, assume. Yet none of these latter terms is quite unassailable, and it may even be claimed that no nosological term will ever be impregnable. Witness the very considerable vogue of Babinski's proposal of Pithiatism for Hysteria, the latter term logically inappropriate enough, but (everybody thought) a perfect succes de scandale. Yet a very real progress was registered by the discussion which ensued upon Babinski's thesisand one may concede the progress without accepting the thesis. In short, we should maintain a constant theoretical fl uidity in the nomenclature of CLASSIC TEXT NO. 72: E. E. SOUTHARD [1919] mental diseases, despite a solid practical agreement from decade to decade as to the terms we shall use for accepted entities.

In the midst of this theoretical fl uidity of terms, can we agree on Dementia Praecox as in any sense an isle of safety in present-day traffi c? But, is Schizophrenia safer?

Before answering these questions, one may pause to consider whether there is any such entity suffi ciently well established to deserve a heated discussion of nomenclature -is there an accepted entity deserving some such title as Dementia Praecox or Schizophrenia? It is not my primary object here to discuss classifi cation, but to limit discussion to nomenclature and the terminological diffi culties that the Krapelinian nomenclature leads us into. But the deeper and more fundamental question of classifi cation still remains open. For some years past I have spent a good deal of time on the anatomical side of the question. Anatomical solutions are diffi cult by reason of the grave doubt which may attach to the clinical diagnosis of a large minority of cases of so-called Dementia Praecox. I conclude that there are a few (but a very few) cases of so-called Dementia Praecox that do not possess demonstrably anomalous brains and that all cases of Dementia Praecox (except possibly those of a few weeks or months duration) show demonstrable microscopic cortex changes. Concerning the anomalies, I see nothing therein to indicate that a person with such an anomaly needs must go the clinical way of Schizophrenia. Nor is there really anything differential in the microscopic lesions found, if we abstract from the situation of the lesions. But, if the nosologist should claim (on the basis of the occasional absence of brain anomalies and the non-differential quality of the cortex changes found) that Schizophrenia is a disease as "functional" as so-called manic-depressive Psychosis, I should be inclined to deny the nosologist that right. For very few, if any, cases of so-called Manic-depressive Psychosis show such brain abnormalities as cases of Schizophrenia. In fact, in my experience, the brains of so-called manic-depressives (cyclothymias I prefer to term them) are not grossly distinguishable from the brains of normal persons with respect to anomalies. Now, suppose we grant the existence of gross brain anomalies in Schizophrenia (and concurrently grant their relative non-existence in General Paresis, in Cyclothymia, in normal subjects), is it at all necessary to conclude that Schizophrenia is an entity? I think not, for a variety of reasons. For one reason, the anomalies of the brain in Schizophrenia often strike one as of embryonic or early origin and shade over into the usually more pronounced and bilateral anomalies of the feeble-minded brain. It is clear that a brain anomaly is a pretty wide-meshed sieve that could let through all sorts of conditions. There is no reason in the brain anomalies for asserting the unity of Schizophrenia.

A logically identical argument runs from the microscopic lesions. Their universality in the brains of schizophrenics does not argue the unity of schizophrenia, any more than the universality of microscopic lesions in senile psychoses allows one to assert the unity of the senile psychoses.

In fact, both the gross anomalies and the microscopic changes are entirely consistent with a tremendous clinical variety in conditions known as Schizophrenia. They are also consistent with great variations in curability. For it seems clear that these anomalies may exist in a man's brain for decades without the appearance of a psychosis. And the microscopic lesions are far less striking than those in General Paresis, which are consistent with extensive remissions or perhaps with complete (salvarsan) cure. Even the death of numerous neurons seems consistent in general Paresis with relatively perfect restoration of mental health for long periods.

I conclude, then, that for the present neither the anatomy nor the microscopy of cases of so-called Dementia Praecox indicates with more than probability the existence of an entity. In some recent papers I have approached the question of fi ner correlations of a stratigraphical and topographical nature with some of the more defi nite symptoms in Schizophrenia. However interesting or suggestive these anatomoclinical correlations may be, it is doubtful whether they throw light on the entity question. Just as the tissue process is largely one of destruction of neurons (neuronolysis) with some reparative or reactive processes superimposed, so the mental processes are largely also destructive or dissociative ("psycholytic"). Where I most signally failed in correlation was with certain synthetic mental processes (a sort of paranoiac concretion of mind). But the majority of processes, from the mental side, are doubtless lytic rather than combinatory: hence the value of Bleuler's term Schizophrenia, "split-mindedness."

Schizophrenia is not the only nomenclatural suggestion that indicates the preference of many workers for some term expressive of the psycholytic nature of most of the phenomena in the group. The Dementia sejunctiva of Gross is an analogous term with Wernickean reminiscences. The neat adjective "sejunctive" ought, one believes, to be used more frequently of psycholytic processes of various sorts. But "dementia" has decisive drawbacks (see below). A like argument holds for Dementia dissecans of Zweig. Dysphrenia, proposed by Wolff, is an example of terms logically too wide, covering virtually all forms of mental diffi culty that are predominantly intellectual in their symptoms, and hence inappropriate for purely psycholytic processes.

It seems to me, therefore, that the statistical committee of the American Medico-Psychological Association is very sound in allowing the use of Schizophrenia as a term in place of Dementia Praecox. Schizophrenia at least means something fairly defi nite, referring as it does to a disease in which splitting or dissociation processes occur. Precisely insofar as the association theory holds good in psychology, just so far will it be possible to render the facts of psychopathology in terms of dissociation. The "mental chemistry" of John Stuart Mill, so far as it is valid at all, will prove to have its analytic as well as its synthetic division. Observing processes of hallucination, "disruption of judgment," emotional apathy, catatonia, we ask: What has split this mind? What is dissociating the processes that normally run together? And we conclude that, whether the interruption of mental processes be by means of hallucination, emotional or volitional disorder, the result is an interference with the normal fl ow of thought, not readily named better than by the term Schizophrenia.

But does not priority so rule as to give Kraepelin the right to his own designation, Dementia Praecox? Not, I believe, if the term conveys a logically wrong impression and pragmatically tends to injure the patient's prognosis. Kraepelin himself has shown a willingness to use the term schizophrenic of various symptoms and even in a later edition of his text book re-labels certain patients "schizophrenic." Moreover, Kraepelin, has himself named a variant of his Dementia Praecox, following the analogue of Bleuler's term, Schizophasia (Wortverwirrtheit). In general he now tends to think of a larger group of cases as "endogenous deteriorations," a group containing nine variants of Dementia Praecox and four of so-called Paraphrenia. We are entitled to believe, I think, that Kraepelin not only did not in 1899 carry his synthesis of entities far enough, but also lent an unfortunate weight to the designation, Dementia Praecox -really only an intermediate product in the logical digestion of mental diseases.

The group of so-called "endogenous deteriorations" (Dementia Praecox and Paraphrenia) has not been given a Hellenized or Latinized scientifi c name by Kraepelin. I have myself proposed to follow the suggestion of Bleuler and adopt the term Schizophrenia as a general name for sundry of these diseases. I have further proposed the uniting of these genera into an order, Schizophrenoses. This order, Schizophrenoses, would stand to its included genera (of Schizophrenia simplex, Catatonia, etc.,) as Rosaceae to Rosa gallica, Rubus strigosus, etc. Just as the roses, in the extended sense of Rosaceae, include not just nosegay French roses but also American red raspberries, so the "mind-splits" would include not only simple "splits" but "muscle-hypertensives" or whatever you wish in common parlance to term the catatonics.

Not only does Kraepelin himself incline to the use of the schizo-concept of Bleuler at least in symptom descriptions, but also he has left unnamed (scientifi cally speaking) the larger group in which these cases belong. Finding it desirable in recent work to name scientifi cally all the larger groups of mental disease, I found no terminological diffi culty greater than in this very group, characterized so far as I could see chiefl y by the common factor of "splitting," dissociation, sejunction, schizophrenia. Finding that "schizophrenia" would readily form compounds, especially adjectives, I adopted the term as the basis of the group designation, Schizophrenoses, on par with Syphilopsychoses and Epileptoses.

My more general propositions concerning the great groups of mental disease ought to get reasonably good reception in America, representing as they do with a slight rearrangement nothing but the main groupings of representative American textbooks. Incidentally, I feel that these groupings and that of the Schizophrenias in particular, go far to cut under the main objection which Adolf Meyer had brought to the results of the labors of the Statistical Committee of the American Medico-Psychological Association. "That our own committee on statistical classifi cation," says Meyer, "should at this late hour have sworn allegiance to the German dogma without provisions for mixed and merely allied types (italics mine) * was a somewhat distressing surprise. Fortunately we still constitute a free country and have reason to hope that if a cause is just it will ultimately fi nd a majority."

The general impression which I retain from modern American diagnosticians is that the term "Dementia Praecox" attaches more to a group of probable and possible entities than to any single supposed entity. If this is the acceptable view to most American diagnosticians, I hold that this view is in accord with Kraepelin's own trend to larger syntheses, with Bleuler's grouping of over a score of entities or conditions under Schizophrenia, and with Meyer's plea for less nosological rigidity.

We must all agree with Meyer that the last point in psychiatric work is "weighing the case" according to whether the case does or does not coincide with a well-defi ned practical type "so that it may be" classifi ed as identical with, or akin to, "a standard unit such as we keep for our statistics and for elementary teaching." Also we must heartily agree with Meyer's dictum that "we may have to get away from the idea of 'one person, one disease.'" At least we must do so if the distinction rests on the thought that the American red raspberry is as distinct from the French rose as it is from the crabapple. The genus-species distinction allows great latitude in descriptive analysis of cases. If the higher grouping of the "orders" is superadded to the genus-species groupings and a generous sprinkling of varieties be allowed for the subdivision of the species, a tremendous range and nicety of diagnosis is permitted. Now Meyer's own process he briefl y describes as in the fi rst place a sort of rough grouping not far if at all removed from the processes of other workers. Thus says Meyer, "I force myself fi rst to get my facts concerning the totalreaction or reaction-type or reaction-complex." What are these? Meyer's (possibly incomplete) list is "organic, or toxic-delirious, or affective, or paranoiac, or a benign or a malignant substitutive process, or a constitutional defect or perversion, or a mixture."

Accordingly, when Kraepelin tries to effect a fi rst synthesis of older entities under the name Dementia Praecox and proceeds later to evolve a larger synthesis under the name Endogenous Deteriorations, he arrives at a broad grouping that reminds us of some of the best French work and is on all fours with the above quoted groupings of Meyer -the so-called reaction-types. Is there any essential difference in the logical idea that lies at the bottom of Kraepelin's Endogenous Deteriorations, of certain of Meyer's Reaction-types, and of the Bleuler concept of the schizophrenias? Is it not a question merely of the better way of saying the same sort of thing?

According to Meyer's gibe, Kraepelin created "manic-depressive insanity," "dementia praecox," and a few other entities, "in a fi t of indignation against Ziehen" and praised them to the world "owing to the prognostic virtues and ultimate simplicity of his nosological schemes." It is very doubtful to my mind whether Kraepelin created any new "entities" whatsoever. It seems to me that he did nothing more than regroup some old entities in a more or less profi table way. It seems to me that Kraepelin's chief contributions have been synthetic rather than analytic -witness the "dementia praecox" group now swollen to include various "endogenous deteriorations," witness also the "manic-depressive group" with its various "forms," witness his more recent efforts at synthesizing the "psychogenic psychoses," witness the vaguer efforts at calling hysteria and paranoia both infantilistic.

Omitting superfi cial differences, are not modern psychiatrists at one in developing the idea of certain classes of mental disease that represent higher and more general categories than the familiar entities of the books? And, if this tendency to more general groupings is as sound as it appears to be widespread amongst psychiatrists of every stripe, shall we not seize the opportunity to give these more general groups the most appropriate designations? In particular, shall we not with most meticulous care see that the objectionable term "Dementia Praecox" does not get attached to that higher grouping in which so-called Dementia Praecox in nine forms and Paraphrenia in four forms appear, viz. Kraepelin's "Endogenous Deteriorations"? Personally I hold no brief for the term "endogenous deteriorations," because the term "deterioration" is so broad as to let in the tide and because the term "endogenous" commits us to a particular kind of (unproven) etiology. But, though the term is not perfect, it is manifestly superior to Dementia Praecox, and Kraepelin can rightly claim to be several laps ahead of critics who confi ne their disfavor to the term Dementia Praecox. Kraepelin has gone on his synthesizing way and, as it seems to some of us at least, has virtually given up the Dementia Praecox idea in its original form.

Aside from the question whether a disease X (sometimes known as Dementia praecox) really exists and aside from any changes of heart which Kraepelin may or may not have experienced concerning this disease X, the fact remains that the term "Dementia praecox" still persists to plague us with its inexact denotation and its horrible -I speak by the book, horrible -connotation.

The nineteenth century history of the term has been summarized by Mlle. Pascal, who ascribes the creation of the term to Morel in 1858. Morel, it appears, was really describing what came later to be termed by Kahlbaum in 1874 Catatonia. Morel's list of symptoms of his démence précoce contained nihilism (i.e. negativism), catalepsy, stereotypes, emotional indifference, loss of family feeling, outbursts of laughter, and Morel described the tendency of these cases to mental impairment.

Pascal attributes the long burial of Morel's idea to the preoccupation of the psychiatrists of that day with heredity (it was the early day of Darwinism) and "degeneration." She calls attention to a like burial for a long period of the ideas of Kahlbaum (hebephrenia, 1863Kahlbaum (hebephrenia, , catatonia, 1874)). Doubtless it would be chronologically unlikely that the originators of such ideas as hebephrenia and catatonia would live long enough (or remain scientifi cally active long enough) to learn whether "dementia" was bound to set in and especially to learn whether a peculiar and characteristic "dementia" was bound to set in. Morel's insight -as man of his insights -was remarkable in his choice of the term "demence precoce" (1858) for Kahlbaum's disease "catatonia" (1874), that was later to prove an important constituent of Kraepelin's new synthesis "dementia praecox" (1899). Probably two generations of men will always be necessary for the establishment of any such conception as that of a disease X with a characteristic deterioration, scheduled to take place in certain cases as a period of decades! Perhaps a third generation of men will be necessary for an assessment of the conception's value. Kraepelin had the work of Morel and of Kahlbaum and Hecker in mind when he synthesized his "dementia praecox" from their products. As Mlle. Pascal points out, Morel and Kahlbaum and Hecker could see only symptoms and syndromes and not the disease. Kraepelin could start with the established descriptions of his distinguished predecessors and observe the course and outcome of these symptoms and syndromes. Owing to circumstances connected with my military duties, I did not get around to answer your letter in reference to the possible replacement of the term dementia praecox until today, and now I notice that you were to read your paper last week. So what I have to say is probably too late to be included in your collection of opinions.

I might say, however, that my experience in the Army has made me keenly aware of the existence of a widespread, extremely loose and wholly unjustifi able use of the term dementia praecox. It is apparent that dementia praecox has become the popular designation for the greatest variety of diverse conditions with the result that much unnecessary consternation, anxiety and suffering are caused to both patients and relatives. This is one reason why I would welcome a term with less severe implications, although a single substitute would not in any way advance our knowledge of psychiatry. I do not think that "schizophrenia" is a very good substitute and American psychiatrists have never used the term in nearly so wide and all-embracing a sense as Bleuler who introduced it. I would not, however, in the absence of anything better oppose its recognition in our offi cial diagnostic groupings. I feel that several terms must eventually be devised to provide for the breakingup of what is now included under dementia praecox. The latter will probably remain in use until suffi ciently narrowed down. It is hard to make physicians of limited clinical experience suffi ciently cautious about forcing diagnoses in psychiatry. Good anamneses, a careful study of the evolution of symptoms and their general setting and a reasonable period of observation must continue to form the foundation for clinical differentiations and prognoses. A great many cases can not of course be worked up satisfactorily in army practice or in clearing houses or clinics where cases are rapidly disposed of. I fi nd that physicians without a State hospital experience are much more free in making diagnoses of dementia praecox than are physicians attached to State institutions. Incipient and non-institutional cases are probably more diffi cult to classify than cases which reach State hospitals. I have considerable evidence to show that the dementia praecox group in the best State hospitals is quite as defi nitely and satisfactorily circumscribed as is the manic-depressive or the alcoholic group and, until recently, as even the general paralysis group.

Yours very sincerely,

[signed] George H. Kirby

Southard's quotation from a letter (date unknown) from Albert M. Barrett

Dr. Albert M. Barrett on the extirpation of the term "Dementia Praecox."

For some time past, in this clinic, we have been using the term "dementia praecox" less frequently. Without having taken a fi xed attitude in the matter we have happened to use the term "schizophrenia" in a more or less interchangeable way with dementia praecox. A considerable number of cases, which formerly might have been placed in the group of dementia praecox, have come to be placed under the heading of paraphrenic disorders.

We have appreciated that schizophrenia conveys a clearer expression of the disorder than does dementia praecox. It fi ts in better with the interest that is now shown in the underlying factors in the development of psychoses. It conveys a description of a purposive mechanism rather than of a group.

Discarding the term "dementia" is an advantage in teaching. It is always diffi cult to maintain in the student's mind the distinction between the dementia of dementia praecox and that of organic psychoses.

It would be a gain also in the matter of prognostic distinctions. The assignment of a case to the group of dementia praecox had always implied a greater degree of hopelessness in the outcome than experience warrants. In this respect the term "schizophrenia" is less committal as to the outcome. It emphasizes more the aspect of the development of the disorder and places etiological factors in the foreground that may be taken advantage of in therapeutic directions.

Schizophrenia is not altogether a satisfactory term. Schizophrenic mechanisms occur in disorders that would not be regarded as dementia praecox and there are cases of dementia praecox in which the schizophrenic features are impossible to demonstrate in a clear way. On the whole I believe that the term "schizophrenia" is preferable to dementia praecox.

Southard's quotation from a letter (date unknown) from Adolf Meyer

Professor Adolf Meyer writes me in a personal letter as to the attitude of the Phipps Clinic concerning dementia praecox and schizophrenia:

"We use the term schizophrenia and speak of benign and grave forms and residual states. I hope that the elimination of the term schizophrenia will follow, as too broad an entity. I really feel that the elimination of the concept of terminal dementia was a grave mistake, inasmuch as I believe that various processes can lead to the ultimate result, and psychiatry would have been much better off if the fundamental and initial facts had been studied for what is present in the case, instead of dreaming what might be found in the terminal stage and at the autopsy. We certainly want to learn all we can from the autopsy and from the retrospect, but I am inclined to think that the emphasis ought to be laid on the synthetic side of the disease picture, the possibility of its analysis and the singling out of the modifi able points."

Southard's quotation from a letter (date unknown) from August Hoch

Dr. August Hoch writes as to his attitude toward the terms dementia praecox and schizophrenia as follows:

"I do not have such a strong feeling about names as you seem to have and have never felt, for example, like abandoning the term 'shaking palsy' CLASSIC TEXT NO. 72: E. E. SOUTHARD [1919] because the patients sometimes do not shake. Therefore I am not at all certain whether I shall defi nitely abandon the term dementia praecox, since everybody has gotten so used to it, but I quite agree with you that the term is not good for the following reasons:

(1) Not all the cases deteriorate and few deteriorate progressively.

(2) The disease may come on at almost any age.

(3) It is unfortunately too pessimistic a name to use with laymen. (4) I always had a feeling that behind the term dementia praecox there was an idea of some sort of a relationahip between dementia praecox on the one, and senile dementia on the other hand. But with the exception of the fact that you fi nd fat in the nerve cells of both disorders, I can see no parallelism between the two, certainly the clinical structure of the dementia as such is absolutely different and therefore if the name to any one suggests something like such a relationship, this is also a point against it.

"I am not specially pleased with schizophrenia. It is a rather uncouth term, and I remember, when it fi rst came out, how I balked at it and how, when I read my review of Bleuler's schizophrenia at the New York Psychiatrical Society, all of them made a lot of fun of the term. But it is remarkable what one can get used to. Of course a lot might be said against schizophrenia from the point of view of the concept behind it, but we are not talking of this at present. I guess my personal antagonism against discarding completely dementia praecox and standing up for schizophrenia is in part due to a feeling that after all they both imply all sorts of things which are not proven."

Text No. 72 Non-dementia non-praecox: note on the advantages to mental hygiene of extirpating a term by E. E. Southard * [1919]

  Southard papers [GA81, box 8].

	Classic

Letter from George H. Kirby, Director of the Psychiatric Institute of the New York State Hospitals, Ward's Island, to Dr. E. E. Southard, February 24, 1919

	Dear Doctor Southard:

* Southard's spelling and punctuation are retained; words that are underlined in his typescript are printed here in italics.

CLASSIC TEXT NO. 72: E. E.SOUTHARD [1919]

* The words in brackets were added to the typescript in Southard's handwriting.


Margaret L Arnot
email: m.arnot@roehampton.ac.uk

Essay Review

At last readers of History of Psychiatry have a published monograph about puerperal insanity. 1 Adopting a social constructionist approach, Marland effectively reveals the social, physiological and contextual causality of this nineteenth-century condition, yet manages to convey how it remained 'an untidy, elusive disorder' (p. 178) without any shared understanding of a unique symptomology, or treatment protocol. The author conveys a world more humane than perceived by historians emphasizing the 'social control' function of asylums and more nuanced than that seen by earlier feminist scholars. The argument about the condition's particular temporal location is mainly convincing, although its demise as a disease category was probably less neat than the author proposes: it remained useful as a defence in infanticide trials and remained within the lexicon of some obstetricians and psychiatrists into the early decades of the twentieth century (Grey, forthcoming). Puerperal insanity was the terrifying antithesis of the maternal ideal so central to the development of bourgeois domestic values in this period; and early nineteenth-century constructions of women as sickly and fragile provided the broader medical context for the making of this disease.

Although focusing mainly on the historical specifi cities of this condition, Marland also suggests continuities in human bodily and mental experience. Since Hippocrates there has been an awareness that pregnancy and labour could disturb the mental equanimity of women. In Dangerous Motherhood we gain glimpses of childbed madness from Margery Kempe's medieval torment: 'She would have killed herself many a time as [the devils] stirred her to …' (p. 9), to Andrea Yates in twenty-fi rst century Texas who claimed that her fi ve children whom she drowned 'stumbled because I was evil ' (pp. 204-5). The religious framework essential to understanding the conditions in Kempe's time no longer infl uenced nineteenth-century medical explanations, although the patient's view could still include religious language. General fear of childbirth remains to this day, yet also had a particular role to play in the nineteenth-century context. The reader is probably left with more questions about such continuities than explanations, yet to fi nish reading with curiosity stimulated is the result of the best history books.

What is most historiographically original is Marland's challenge to feminist scholarship. Identifying herself with those who have 'nuanced and revised' (p. 142) both Elaine Showalter's and Mary Poovey's views, Marland accepts that women asylum patients became more visible during the nineteenth century, yet disagrees with Showalter's claim that it was constructions of proper feminine behaviour that explained increasing numbers of female asylum patients. There were more complex social and demographic factors, including variations between institutional practices, higher mortality of male inmates, and women's economic dependence that made them more vulnerable to institutionalization. Women were incarcerated in a proportion appropriate to their numbers in the population at large, and gender did not play a dominant role in diagnosis in asylums [START_REF] Wright | Delusions of gender? Lay identifi cation and clinical diagnosis of insanity in Victorian England[END_REF]). The will and determination evident in Sara Coleridge's diary is used by Marland to question Showalter's characterization of mental affl iction as an 'unconscious form of feminist protest' (p. 91). The author also suggests that medical explanations of women's insanity and doctor-patient relationships did not rest almost exclusively on women's reproductive biology as claimed by Showalter and Poovey. However, Marland acknowledges some accuracy in feminist views, suggesting that these doctors legitimized and strengthened notions that women were physically frail and consequently more susceptible to mental illness. As regards class, far from agreeing with Jane Ussher that working-class women were too busy to be 'mad', Marland discovered many poor women in the harrowing case records of the Edinburgh and Warwickshire asylums, and a recognition among physicians that their poverty could have contributed to their loss of reason. Marland suggests that the diagnosis could have been positive for the women themselves, 'opening up the possibility of respite from household and maternal duties' (p. 142). Women who remained in asylums until their deaths may have found a life with more comfort, security and better nutrition than any other option. It is hard to imagine a more damning indictment of a society's gendered power structures than this.

Readers of History of Psychiatry will be interested in the status of the disease as an ambiguous category 'in terms of knowledge and treatment' (p. 35). Throughout the book, the different claims and approaches of midwifery practitioners and alienists are explored. They all agreed that the disease existed in two forms: mania and melancholia -the former most alarming, the latter most intransigent. Citing widely variant statistical data, Marland concludes that it is impossible to determine how many women suffered from the condition, or whether it was most frequently treated at home or in the asylum. The disease could be 'hidden' by domestic treatment and by different diagnostic practices in asylums. Certainly, medical attention to puerperal insanity contributed to the perception that it was increasing. While a few eighteenth-century midwifery practitioners and alienists mentioned childbed madness, it was early nineteenth-century male midwives who fi rst paid it serious attention. By mid-century it was standard fare in textbooks on women's disorders, and widely known among practitioners. It followed a similar trajectory from specialized writings earlier in the century, into textbooks of psychological medicine by mid-century. Marland suggests that there were preconditions for the invention of the diagnosis. Reproduction was seen as a risky business after the death of Princess Charlotte in childbirth in 1817, encouraging greater medical intervention into childbirth. Traditional female support networks were increasingly excluded from the lying-in room, creating isolation and intensifying fear associated with childbirth, which medical men then sought to pacify by expert guidance. The rise of male midwifery and obstetrics, psychiatry, lying-in hospitals and asylums provided the 'experts' and the professional settings for the accumulation of experience. There were different emphases in aetiological explanations, which Marland suggests was at least partly caused by the two different kinds of specialists having patients from different social groups. Midwifery practitioners emphasized the strain of reproductive processes, while alienists highlighted environmental and circumstantial factors learnt through their pauper asylum patients, although all practitioners included references to environmental and social causes in their case notes. Experts from both fi elds agreed on the importance of both physical therapy and moral management in treating patients, but differed regarding the best place for that to occur. Midwifery practitioners tried to keep patients at home, whereas alienists became increasingly convinced that the re-establishment of propriety and self-control was best facilitated in the asylum.

Through the work of Allan Beveridge in particular, regular readers of History of Psychiatry will be familiar with the rich case notes and letters in the Royal Edinburgh Asylum records. It is Hilary Marland's novel use of such sources to explore a particular psychiatric condition, together with the inclusion of case studies, that give the book its particular power. Four brief, contrasting case studies ranging from Queen Victoria to a rural Welsh mother of an illegitimate child draw the reader in at the beginning. Puerperal insanity in wealthy homes is presented in a vivid way in Chapter 3, especially through case studies of Isabella Thackeray and Sara Coleridge. While there is nothing to compare with Sara Coleridge's diary for working-class sufferers, the asylum case notes used by Marland for Chapters 4 and 5 provide accounts almost as intimate.

The main theme of the chapter about Thackeray and Coleridge is domestic disorder presented as both cause and result of puerperal insanity. The physician's role in such cases was not only to cure the patient, but also to restore order to the household and to prevent any recurrence. Removal of a patient to an asylum severed household bonds and signalled the practitioner's failure in this mission. At its worst, this became a domestic tragedy, with children and mothers separated long-term, sometimes for life, which was the fate of Isabella Thackeray, 'dead to us all' (p. 85) according to William Makepeace Thackeray. Sara Coleridge was intermittently separated from her household, often leaving its management to her mother and servant. The reader is taken into the homes, parlours and bedrooms of the affected well-to-do families, and to private asylums and other therapeutic places in Britain and Europe. Marland writes about sufferers, some family members and practitioners with keen observation and compassion. We read of Sara Coleridge's mental sufferings, her physical ailments, the state of her bowels, including her own eloquent descriptions of melancholic states, as she struggled with puerperal melancholia between 1832 and 1843. At the same time a woman emerges who negotiated her way through a minefi eld of mental anguish with a will mostly intact, and determined to control who her medical advisors were, to adhere to whichever advice she chose, and to hew out space to read and write.

Chapter 4 takes the reader into the 'galleries' of the Royal Edinburgh Asylum. The patients' behaviour is vividly described: ranting, tearing their clothes, defecating inconveniently, seducing doctors, masturbating, repeatedly reciting scripture, refusing food or communication, self-harming, attempting suicide, destroying asylum property and assaulting other inmates. Medical literature discussing symptoms is analysed, and we sense the doctors' satisfaction that many of these women were successfully restored to their families. Marland's historical argument about their perceived difference from other psychiatric patients would have been strengthened by comparing the case notes of women classifi ed as suffering with puerperal ailments with those of patients classifi ed differently. That said, both patient experience and doctors' perceptions are presented here with immediacy. With a clearly-recorded diagnosis written at the top of each patient's entry (in these cases, 'puerperal mania', 'puerperal melancholia', 'insanity of pregnancy' or 'lactational insanity'), the case notes refl ected David Skae's (1814-73) classifi cation system based on the relationship between physiological and psychological states [START_REF] Skae | A rational and practical classifi cation of insanity[END_REF][START_REF] Skae | The Morisonian Lectures on Insanity for 1873[END_REF][START_REF] Skae | The Morisonian Lectures on Insanity for 1873[END_REF]. Understandings of aetiology and treatment regimes outlined in the case histories bring to life an holistic mid-century understanding of mental affl iction that saw body and mind as integrally related, and impacted by both moral considerations and environmental factors such as poverty, poor nutrition and domestic strife and disorder. Therapeutic regimes focusing on both physical and moral treatments can be rationally linked to this aetiology, yet what also emerges is a pragmatic, empirical practice that responded to immediate need and explored various alternatives until something worked.

Most patients received mild treatments comprised of a good diet, rest, purges to ensure bowel regularity and, above all, moral therapy such as occupation 'through work, exercise and rational pursuits' (p. 99), and the re-instilling of ordered diurnal rhythms and a self-controlled demeanour.

Yet at an individual level, particularly malnourished (or food-refusing) patients could be force-fed, and refractory patients could be subjected to the trials of 'heroic medicine': blistering, powerful medicines that could include both stimulants, opiates, other anodynes and ointments, cold baths, and being placed in isolation. The number of patient 'escapes' mentioned in passing is silent testimony to some patients' intolerance of such treatment, though another story has a patient returning after release saying she preferred it at the asylum. Although Marland notes a surprising lack of moral censure in the case notes, the infl uence of physiognomy and phrenology could lead to cruel judgements: 'few patients excited the vehemence of Jane Stirling, with her "ill-shaped head" refl ecting her intrinsically, irredeemably bad character' (p. 113). I was left wondering why Marland did not undertake some basic statistical analysis of her cases to compare with the data she presents collected by John B. Tuke (1835Tuke ( -1913) ) when he was Assistant Physician at the asylum between 1864 and 1865. Some simple use of descriptive statistical tables or charts would have helped to elucidate much of the information presented in the chapter, yet if any reader still needs to be convinced of the value of case notes as sources, this chapter will do the trick.

In Chapters 5 and 6 Marland argues that the most important element beyond women's perceived biological fragility affecting understandings and treatment of puerperal insanity was motherhood and family problems. Doctors recognized that motherhood could be very diffi cult, and families were frequently the butt of medical criticism. As well as providing woefully inadequate care, families could mislead doctors, and could disrupt households and patients enough to cause insanity in the fi rst place, and then prevent recovery from it. Removal from family infl uences was considered crucial. Husbands specifi cally were very often seen as beyond the pale, 'an outright danger' to their wives' sanity (p. 161). The doctors' condemnation was mirrored by the women's hatred of their husbands; Dr Robert Boyd of Somerset County Lunatic Asylum believed this to be as much a characteristic of the disease as women's hatred of their babies. This medical criticism of family relationships had something in common with Frances Power Cobbe's campaign on behalf of women needing to escape marriages, and perhaps more could have been made of this intriguing possibility that feminists and medical men had some ground in common. It would be very interesting to consider how the critique of husbands relates to contradictions within the domestic expectations of men in the nineteenth century -something that would strengthen the gender analysis of the book [START_REF] Davidoff | The Family Story[END_REF][START_REF] Wiener | Men of Blood[END_REF]. Husbands were not the only hazard to child-bearing women. Alienists considered that the long periods of breast-feeding common for working-class women made them more vulnerable to puerperal insanity, as did poverty, malnutrition, physical exhaustion, and the demands of rearing large families. For wealthier women, physical luxury and lack of preparation for childbearing were blamed, too, while they shared with poorer women vulnerability to lactational insanity if they breastfed too long. Bearing children out of wedlock was also seen by the majority of doctors as carrying particular risks for puerperal insanity: anxiety caused by poverty, amplifi ed by the fear and sense of disgrace associated with bearing an illegitimate child, were particularly to blame.

Sympathy for unmarried mothers suffering from puerperal insanity accords with the frequent lenience of the courts in the nineteenth century when dealing with mothers who were accused of killing their own newborn infants. The author has been able to link the court records of some infanticide cases with asylum admissions in Warwick. The varied views of infanticidal women within the asylum -immune to or distressed by their crime, treated generally with compassion, some being successfully returned cured to their families, some returning to the asylum again and again -all this makes a valuable contribution to the social history of infanticide. Marland also adds to our understanding of the ways in which lay, medical and legal views contributed to the outcome of insanity defences in the nineteenth century (Eigen, 2005). Puerperal insanity became increasingly available as a defence (it moved into forensic texts mid-century) at about the same time as the mid-Victorian 'infanticide panic' created a yawning gap between some areas of public opinion, horrifi ed by the alleged levels of infanticide, and the continuing lenient practices of the courts. The defence served as mediation between these two positions and provided a seemingly 'scientifi c' explanation for behaviour previously seen as just senseless. Despite the infanticide panic, all concerned (neighbours, witnesses, judges, jurors, medical men, laymen) seemed keen to embrace the label of insanity that meant these women escaped conviction for murder, but also enabled retribution of a different kind. Infanticide was the very worst possible outcome of a mental affl iction that threatened unpredictable violence. Puerperal insanity itself was seen as a risk for all parturient women, because the trauma of child-bearing was considered to be a key cause: all this leads to the argument that 'infanticide … was not seen as the antithesis of but as an intrinsic part of motherhood' (p. 200). The argument that at this time all working-class women were seen to be capable of committing infanticide by neglect has already been made [START_REF] Arnot | Infant death, child care and the state: the baby-farming scandal and the fi rst infant life protection legislation of 1872[END_REF], but Marland's book increases understanding of the implications of nineteenth-century views of women's constitutions. If no woman was strong enough to be capable of motherhood without the risk of insanity and infanticide, women's greatest strength, and a fundamental plank of feminist calls for greater political acknowledgement, was undermined. Insanity and infanticide were certainly not attributes to be drawn on in any positive way in the public domain, and all the more reason for both medicine and developing state institutions to invent the notion that women needed expert guidance in mothering. It is a pity that Marland did not explore these broader implications of her argument.

In her fi nal chapter Marland's critique of the disappearance of the diagnosis with the rise of Kraepelian diagnostic categories is informed by a gender politics that seeks the best treatment for individual sufferers. Marland considers twentieth-century therapeutic regimes to be harsher, and cites the recent Texas case of Andrea Yates as evidence of much less sympathetic treatment in the judicial process when the insanity defence is raised in infanticide trials, though reference to recent British cases would have been of more relevance to this book. In contrast, nineteenth-century alienists emerge as dedicated men striving to do the best for their patients, and the asylums as places of refuge where women were administered treatments that were usually gentle, were given time to heal, and where recovery rates were good.

Dangerous Motherhood will make valuable reading for historians of medicine and psychiatry and for scholars in gender studies. The combination of accessibility with excellent scholarship ensures its appropriateness for both undergraduate and postgraduate courses. Elegance is at times a little compromised in favour of stylistic clarity, but that is a small gripe about an excellent book. More annoying are: a few minor bibliographical inaccuracies that should have been avoided; and the fact that statistical data referred to in discussion are not always in commensurate form, making comparisons diffi cult. The book is rich in evocative descriptive material, but at times analysis could have been deepened.

Dangerous Motherhood contributes to many areas of understanding; ideologies of domesticity, femininity and maternity; the medicalization of women; relationships between doctors, patients and their families; medical practitioners' ambitions to establish their reputations and practices, and their concerns to cure patients and relieve families of the burdens of puerperal insanity; and ideas of female madness among the wealthy and poor in the Victorian period. Every reader of this journal should be very well rewarded by reading this book.

Note

Studies remaining in dissertation form:[START_REF] Day | Puerperal insanity: the historical sociology of a disease[END_REF][START_REF] Nakamura | Puerperal insanity: women, psychiatry, and the asylum in Victorian England, 1820-1895[END_REF][START_REF] Quinn | Include the mother and exlude the lunatic: a social history of puerperal insanity, c. 1860-1922[END_REF]

Acknowledgements

The editor would like to thank the Members of the Advisory Board, the assistant editors and the many colleagues for their sterling help with the onerous task of refereeing the papers submitted to History of Psychiatry. It would be diffi cult to run the journal without their generous support.

Thanks are also due to the Book Review Editors whose industry and perseverance maintain one of the important sections of our Journal.


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Thomas Beddies. Book Review: Eric J. Engstrom and Volker Roelcke (eds) (2003) Psychiatrie im 19. Jahrhundert. Forschungen zur Geschichte von psychiatrischen Institutionen, Debatten und Praktiken im deutschen Sprachraum (Akademie der Wissenschaften und der Literatur Mainz: Medizinische Forschung, Band 13) (Basel: Schwabe). Pp. 294. ISBN 3-7965-1933-4 (pbk). History of Psychiatry, 2008Psychiatry, , 19 (1), pp.91-93. 10.1177 Forschungen zur Geschichte von psychiatrischen Institutionen, Debatten und Praktiken im deutschen Sprachraum (Akademie der Wissenschaften und der Literatur Mainz: Medizinische Forschung, Band 13) (Basel: Schwabe). Pp. 294. ISBN 3-7965-1933-4 (pbk).

This volume is based on a conference held in Berlin in 2001 which focused on nineteenth-century psychiatry in the 'scientifi c nation' (Benoît Massin) of Germany, Switzerland and Austria. In the introduction the editors, Eric Engstrom and Volker Roelcke who are well-known authorities in the fi eld, outline the book's basic aims and objectives. They draw attention to two different historiographies of psychiatry, one with a strong presentist interest in contemporary twentieth-century history and current affairs, and another less-presentist, longer-ranged historiography that takes the phenomena and contingencies of 'older' nineteenth-century psychiatry as the focal point of its analysis. The editors see the book as a contribution towards an enhanced dialogue between these two historiographies. Many important aspects of the historiography of nineteenth-century psychiatry in German-speaking countries are dealt with in the ensuing eleven contributions. Conceptually, the book has three main threads of analysis: fi rst, it approaches the history of psychiatry in the nineteenth century as a history of the relations between psychiatry and other neighbouring disciplines and/or institutions (military, church, state, the public sphere); second, it analyses the strategies that psychiatrists deployed in order to stabilize the legitimacy of their discipline and to enlarge its radius of operation; and third, it seeks to enhance serious analysis of historiographic narratives, stressing how different ideas and research priorities have moulded our understanding of nineteenthcentury psychiatry.

It is primarily this third thread of analysis that Michael Kutzer undertakes in the book's fi rst chapter, revealing just how tentative and questionable our historical preconceptions are. Drawing on the example of the conceptual dichotomy of 'Psychiker' and 'Somatiker', he shows how historically contrived the juxtaposition of those two terms has become and that, in fact, the views of the two different 'schools' overlapped in many areas.

In the next chapter, Alexandra Chmielewski discusses the distinction made between asylums for curable und non-curable lunatics in the nineteenth century. Drawing on the example of the 'Heilanstalt' and the 'psychiatrische Klinik' in Heidelberg/Baden, she shows that on a day-to-day basis the ideal of a strict distinction could not be realized in these institutions. David Lederer also focuses on institutionalization and the 'birth of a madhouse', in this case in Munich/Bavaria; he stresses the discrepancy between the intended aims of the asylum (for example, security and effi ciency) and the diffi culties that arose in trying to realize those aims in the construction of asylums in the real world.

Kai Sammet discusses the 'non-restraint-system' at the Charité-Nervenklinik in Berlin. In doing so he focuses on Wilhelm Griesinger as an example of a liberal, middle-class, civic psychiatry in mid-nineteenth-century Germany. He hastens to point out, however, that the view of Griesinger as a representative of humanist values is oversimplifi ed.

Eric Engstrom deals with the education of students in psychiatric and neurological clinics (i.e., teaching hospitals) in the 1880s and 1890s. He emphasizes that training in psychiatry had long been characterized by practical, on-the-job training in the asylums. Yet the professionalization of training (including the introduction of lecture halls, textbooks and examinations, alongside new licensing regulations, strengthened the position of academic psychiatry vis-à-vis alienist interests. In a further example of strategies designed to enhance psychiatric expertise, Harry Oosterhuis writes about Richard Krafft-Ebing who 'like other late nineteenth-century psychiatrists […] sought to raise the scientifi c and social prestige of psychiatry by extending its boundaries' (p. 167). Oosterhuis claims that the psychological approach of Krafft-Ebing was professionally useful, mainly because it attracted middle-and upper-class patients, especially women, 'suffering from rather mild disorders like nervousness, neurasthenia, or specifi c forms of sexual perversion ' (p. 167).

Volker Roelcke discusses the importance of offi cial statistics on mental diseases for psychiatry -and psychiatrists -as they sought to enhance their status and reputation within the larger community of medical professions. In this context, he accentuates the importance of Emil Kraepelin and his infl uential 'Krankheitslehre', that provided psychiatry with a consistent nomenclature as a basis for further research. But this development towards scientifi c psychiatry was not responsible for the increasingly diffi cult relationship that existed between psychiatry and the general public at the end of the century. According to Ann Goldberg, the main problem was the actual situation in the asylums. This point is clearly illustrated in her chapter on the psychiatric reform movement ('Irrenrechtsreformbewegung') in the fi nal decades before World War I.

Urs Germann explores the increasing importance of psychiatric expertise and jurisdiction, based on a study of the Swiss canton of Bern. He identifi es the delicate balance between juridical and psychiatric competence as being the result of a long learning process. Martin Lengwiler focuses on the role of a different aspect in his examination of the role of military psychiatry in the development of psychiatry at the beginning of the twentieth century. He provides a cogent description of intelligence tests as instruments that were used to demarcate the border zones ('Grenzzustände') between mental health and illness. A similar theme is addressed in the fi nal chapter of the volume by Peter Schmiedebach and Stefan Priebe, who discuss different models of open psychiatric care (social psychiatry) in late Imperial Germany.

The editors hope that the contributions to this volume will form the basis of further research along the lines set out in the introduction. And indeed, most of the chapters do move debate and research on nineteenth-century psychiatry forward. Currently in Berlin, researchers are building and expanding on some of the ideas touched on by the contributors, especially the issue of borderline conditions and their cultural permeability in the wider context of urban culture.

THOMAS BEDDIES Charité -Universitätsmedizin Berlin

Michael Tyquin ( 2006) Madness and the Military: Australia's Experience of the Great War (Canberra: Australian Military History Publications). Pp. xv + 180. Au $70.00. ISBN 1-876439-89-0.

Although the cover's depiction of Edvard Munch's 'The Scream' is hardly imaginative regarding a work on neuroses, this groundbreaking analysis of Australian soldiers who suffered psychologically in World War I goes on to dispel many long-cherished views. Notably, the archetypal 'Aussie' war hero -the easy-going, courageous Digger consistently portrayed by Charles Bean (Offi cial War Historian) is largely shown to be a fabricated myth. Detracting from this popular image, Tyquin reveals that many Australian troops -like their counterparts in other armies -simply crumbled mentally under the horrifi c strain of the Great War.

The unsympathetic attitude of the military towards nervous complaints is equally emphasized, many sufferers being offi cially viewed as prone to hysteria or merely 'shamming'. Remarkably, this opinion also gained the authoritative support of Colonel Arthur Butler, who drafted Australia's offi cial medical history of the war. This lack of contemporary knowledge concerning psychological disorders within the medical profession and the inability to treat 'shockies' (nervous cases) effectively is also comprehensively analysed. Among the most interesting discussions are those regarding the wide variety of unsuitable, discomforting treatments which were given to patients, and the common refusal to implement Freudian ideas, owing to many of his theories outraging Edwardian prudery!

  und Praktiken im deutschen Sprachraum (Akademie der Wissenschaften und der Literatur Mainz: Medizinische Forschung, Band 13) (Basel: Schwabe). Pp. 294. ISBN 3-7965-1933-4 (pbk) Thomas Beddies

  /0957154X07083486. hal-00570913 History of Psychiatry, 19(1): 091-100 Copyright © 2008 SAGE Publications (Los Angeles, London, New Delhi, and Singapore) www.sagepublications.com [200803] DOI: 10.1177/0957154X07083486 Book Reviews Eric J. Engstrom and Volker Roelcke (eds) (2003) Psychiatrie im 19. Jahrhundert.


Dr Karl Ludwig Kahlbaum

Ewald Hecker

Abdullah Kraam
email: a.kraam@leeds.ac.uk

Ewald

Keywords: Hecker, history, Kahlbaum

The chaotic psychiatric nosology of the late nineteenth century needed a strong and new foundation, but when Kahlbaum died in 1899, some German psychiatrists realized that a great opportunity had been missed: his proposal to classify psychiatric disorders according to their course and cross-sectional symptomatology had largely been ignored by the psychiatric establishment. Kahlbaum died in coma diabeticum without the official recognition for his

Introduction

This obituary by Ewald Hecker 1 (1899), Kahlbaum's friend and disciple, gives an account of his personal life and his contributions to late nineteenthcentury psychiatry. It fails however to provide a convincing answer to three questions. First, why was the publication of one of the most thoughtful and thorough classifi cation attempts in psychiatry almost completely ignored by the academic establishment in Germany? Second, why did Kahlbaum publish so little despite clear evidence that he had collected a vast amount of clinical material, which could have supported his classifi cation system? Third, why did he not allow Hecker to publish some of his material after the success of his paper on hebephrenia (Hecker, 1871)?

One of Kahlbaum's fi rst decisions after graduating and spending a year in the army was to accept a position as second physician at the asylum in Allenberg with Bernhardi as his superior. Hecker alludes to the meanness of the director and to the poor salary. It is a matter of speculation why Kahlbaum chose Allenberg in the fi rst place. Was it the closeness to his parents' home 2 or for material reasons? 3 Kahlbaum, and later Hecker, both tried to humanize the treatment of patients in Allenberg but without success. There seems to be no doubt that the conditions in the asylum of Allenberg were harsh for patients. Progressive psychiatrists like Hecker and Kahlbaum appear to have been shocked but unable to change anything for the better. Wilmanns 4 said in Hecker's obituary that, even in the absence of the Director who was on sick leave, Hecker's attempts to introduce a more humane treatment was blocked by the nursing staff (Wilmanns, 1924).

Kahlbaum's efforts to establish himself as a lecturer in Königsberg must have been even more frustrating. Travelling from Allenberg to Königsberg proved quite expensive, and Kahlbaum received an additional grant of 200 thalers for two years from the Prussian Culture Minister, but only after numerous applications. Nor was he successful in persuading the Ministry of the importance of teaching medical students in clinical psychiatry: he had no patients for his lectures at Königsberg and his attempts to arrange for the students to travel to Allenberg were ultimately not approved.

Three years after the publication of his Die Gruppirung (1863), Kahlbaum decided to accept the offer to become second physician and ultimately Director of the private asylum in Görlitz. At this stage, did he give up his pursuit of an academic career, frustrated by the lack of response of the psychiatric establishment? 'No university appointed him', as [START_REF] Ziehen | Nekrolog Karl Ludwig Kahlbaum[END_REF] wrote in his obituary of Kahlbaum.

Kahlbaum certainly appears to have committed himself with all his time and energy to clinical and managerial work, reforming all aspects of his clinic (including drawing his own sketch for a ceiling fresco symbolizing science for one of the halls). In 1875 the clinic was in very good shape, with a noted reputation and a constant fl ow of patients. Kahlbaum had just published his monograph on catatonia (1874), and his decision to take a sabbatical year was timely. It is interesting, however, that he used the year to advance his knowledge in pathology, anatomy and microscopy rather than focusing on writing up the clinical treatise which he had promised; in fact, there was a fouryear gap between his book on catatonia and his next publications. And he did not allow Hecker to do it for him! It is tempting to speculate that Kahlbaum was jealous of Hecker's success following his publication of hebephrenia (Hecker, 1871), and the fact that the disease form was more and more associated with Hecker's name rather than his. Is this why Kahlbaum repeatedly emphasized that he had coined the name and had given Hecker all his (Kahlbaum's) material to publish. This hypothesis does not seem to fi t with the description of Kahlbaum's character as described by [START_REF] Hecker | Karl Ludwig Kahlbaum[END_REF]), Neisser (1924) and [START_REF] Ziehen | Nekrolog Karl Ludwig Kahlbaum[END_REF]. They portray him as a stern, hardworking, honest and humble psychiatrist -religious, with some liberal tendencies, an idealist not without a dry sense of humour. All three biographies lament Kahlbaum's lack of recognition in the world of academia, and the refusal to appoint him to a chair of psychiatry or a university post, or at least award him the title 'professor' for his contributions to psychiatry.

We have to conclude that psychiatry was not ready for a 'modern psychiatrist' 5 like Kahlbaum and his Die Gruppirung in 1863, and nor was it ready in 1899 when he died in coma diabeticum. So psychiatry took the route it took because Kahlbaum was ignored ('totgeschwiegen' as Ziehen (1899) chillingly remarked) and because, of the two other opposing psychiatric giants of that time who had recognized Kahlbaum's importance, one died prematurely following a bicycle accident, 6 thus giving the other 7 the opportunity to mould psychiatry on his terms for one hundred years to come.

Notes

1. Ewald Hecker (1843Hecker ( -1909)): studied medicine in Königsberg; disciple and friend of Kahlbaum and worked as his deputy in Görlitz until he set up his own private asylum in Wiesbaden. For a detailed biography, see [START_REF] Kraam | Ewald Hecker (1843-1909[END_REF]Berrios, 2002. 2. Lauschke (1979) favours this explanation. 3. [START_REF] Steinberg | Karl Ludwig Kahlbaum -Leben und Werk bis zur Zeit seines Bekanntwerdens[END_REF]) theory. 4. Karl Willmanns (1873-1945), studied medicine in Bonn, Göttingen and Berlin; assistant physician in Bremen, Bonn (Director, Pelman) and Heidelberg (Kraepelin); 1918 Professor and Director at the clinic for psychiatry and neurology in Heidelberg. 5. [START_REF] Arenz | Eponyme und Syndrome in der Psychiatrie[END_REF] acknowledges Kahlbaum's modern understanding of psychiatric disorders and his infl uence on the Wernicke-Kleist-Leonhard school of psychiatry. 6. Carl Wernicke (1848-1905). 7. Emil Wilhelm Magnus Georg Kraepelin (1856-1926).

Classic Text No. 73

Karl Ludwig Kahlbaum * by Dr. Ewald Hecker (1899) 1 On 15th April of this year, senior medical offi cial 2 Dr. Karl Ludwig Kahlbaum, owner and director of a private clinic in Görlitz, died at the age of 70. We have lost one of the most important of our specialists whose worthy aim was to advance psychiatry scientifi cally and practically. His reputation and that of his clinic have extended beyond the borders of Germany. His importance as a scientist has gradually gained acceptance as well; his real contributions to psychiatry, however, have only been appreciated by a few, undeservedly according to my opinion. I have had the honour of working and socializing intimately with the deceased over ten years, and was inspired and educated by the richness of his knowledge, his experience and his brilliant mind. I am therefore grateful for having been given the opportunity by this journal's editors to fulfi l, with this obituary, a deeply felt debt of gratitude and devotion.

Karl Ludwig Kahlbaum was born near Driesen in Neumark on 28th December 1828. He studied medicine in Königsberg, Würzburg, Leipzig and Berlin. He gained a doctorate with the dissertation: "De avium tractus alimentarii anatomica et histologia nonnulla". He gained his qualifying degree the same year and after a voluntary year as a physician in Berlin enrolled as the second physician and deputy director 3 in the East Prussian province asylum. In his scientifi c endeavours he did not have much encouragement from his superior, but he did not need it anyway. He familiarized himself with this new fi eld with his typical steely diligence.