Auguste Forel

Bernhard Kuechenhoff
email: bernhard.kuechenhoff@puk.zh.ch

Keywords: Auguste Forel, eugenics, psychiatry, racism, Switzerland

Until the end of the 20th century Forel (1848Forel ( -1931) ) was seen as an important neuroanatomist, a fi ghter against alcoholism, a researcher on ants and the author of Die sexuelle Frage. Forel's racist and eugenic views have been forgotten. Without losing sight of his merits, this article focuses on his attitude

Introduction

Forel's achievements and activities were highlighted in an exhibition in Zürich in 1986 andin Bern in 1988, each accompanied by a comprehensive catalogue [START_REF] Meier | Arzt Naturforscher Sozialreformer[END_REF][START_REF] Meier | Arzt Naturforscher Sozialreformer[END_REF]. They were:

• His extensive research on ants, in which he discovered and described over 3000 new species. • His voluminous work on the anatomy of the brain; he was the fi rst to describe the neuron (and was a contemporary of W. His). • His deep involvement with and use of hypnosis.

• His fi ght against alcoholism and extensive activities in the abstinence movement. • His open debate on the theme of sexuality, and his support in the fi ght for women's equality and against the discrimination of illegitimate children and their mothers. • His pacifi sm.

In the introduction to the fi rst exhibition catalogue, Pio Caroni, then Head of the University of Bern, wrote:

What characterizes his never-ending social-reform activities is what impresses and appeals to us still today: Forel's theories are deeply rooted in his wish for science to be 'useful', i.e., to fi nd solutions to current political and social problems. Therein, perhaps, lies the secret and immediacy of the message of this great and lonely fi ghter: he teaches us to be aware of the social duties and responsibilities which arise from such research and which are easily overlooked or which we are sometimes tempted to suppress. (Meier, 1986: 7) Konrad Akert (who had founded the Institute of Brain Research Zürich in 1962) was Head of the University of Zürich when he wrote in the second catalogue: 'The aim of this exhibition and the catalogue is that Forel's monumental lifework, documented in its entirety, should arise in front of our eyes and remind us of a man who, even today, can act as a role model and whose work still challenges us.' (Meier, 1988: 8).

From today's perspective, this judgement would have to be modifi ed. If certain pointers and remarks in the exhibitions' catalogues are examined more closely, the idea that this is a complete representation of his life must be questioned because Forel's racist and eugenic thoughts and ideas have been ignored. It is therefore necessary to point out his latent racist and eugenic ideas, as well as his appeals for action, so the aim of this article is to draw attention to the various aspects of Forel's work with a particular focus on eugenics. How-ever, even within this framework, it is essential to bear in mind the risk of a biased judgement.

Forel's professional development

Auguste Forel was born in the west of Switzerland in 1848. After his medical studies in Zürich he turned to psychiatry which, at the time, was trying to gain recognition as a branch of medical science. This move towards science, initiated by Wilhelm Griesinger among others, made brain research in German-speaking universities important, and these researchers were appointed to teaching posts in psychiatry at the university.

Forel was also infl uenced by this change of emphasis. As an assistant, he worked with and did research for the leading psychiatrists and neuroscientists of his time such as Theodor Meyner in Vienna, who supervised his doctorate (1871-72), and Bernhard von Gudden (fi rst Director of Burghölzli, 1870-72) in Munich, with whom he completed his qualifi cation for a professorship . His numerous neuro-anatomical and neuro-pathological works are characterized by a terse style and minutely observed detail. In 1887, when Forel published his neuron theory, it appeared almost simultaneously with, but independently from, that of the Basel-born Wilhelm His, then Professor of Anatomy in Leipzig.

In 1879 at the age of only 31, Forel became Professor of Psychiatry in Zürich and Director of Burghölzli. His new clinical duties and lack of additional resources pushed his brain research into the background. In the frequently overcrowded clinic, there were only two or three doctors, including Forel, for over 300 patients. In his autobiography Rückblick auf mein Leben, he vividly describes this initial period at Burghölzli, detailing his confrontation with the clinic's regulations such as his fi ght against alcoholism there; and he also described how he closed the brothels in neighbouring Stephansburg [START_REF] Forel | Rückblick auf mein Leben[END_REF].

It is certainly not easy to imagine the circumstances and conditions at that time. In addition to the lack of staff at the clinic, there was a confusing range of names for the different illnesses. Furthermore, due to the lack of therapies, the clinic itself was seen as a therapy. The experience of daily routine, especially with seriously and chronically ill patients, led to the early acceptance of the degeneration theory of the French psychiatrist [START_REF] Morel | Traité des dégénérescences physiques, intellectuelles et morales de l'espèce humaine[END_REF] with its inheritance paradigm. This theory (i.e., the psychic deterioration from generation to generation) was applied, in the course of time, to almost all psychic illnesses and fi nally also extended to the many varied forms of erratic behaviour. The acceptance that such illnesses could be inherited helped to relieve the pressure on the psychiatrists, as they could not be expected to cure an illness which had been inherited, and therapeutic treatment had limitations. Consequently, prophylactic measures, i.e., the search for ways to prevent these illnesses, became enormously important and meaningful.

These measures included eugenics which will be discussed in detail below. Forel was also infl uenced by the method of dealing with alcoholics in the light of this prophylactic thinking. Having become aware that alcoholism could only be conquered by abstinence, Forel adopted this approach with an almost manic intensity and missionary zeal, both during his time as clinic director and afterwards. In addition, with the lack of appropriate therapeutic alternatives, he had learnt hypnosis, the fi rst psychotherapeutic method, with the leading fi gures of this treatment in France and he used it not only on the patients but also on the carers.

It is remarkable that there are scarcely any written accounts of Forel as a psychiatrist dealing with the most frequent illnesses, known in the terminology of that period as: sanguine moods, fi ts of rage, madness, idiocy, periodic mental illness and cyclic periods of madness. It is known, however, that he worked extensively and intensively on the psychic consequences of venereal diseases and moral insanity, as well as the problem of alcoholism.

As the clinic's director, Forel was much occupied with organizational and legal matters. As the president of the Zürich Society for the Mentally Ill, he published numerous forensic reports and voiced his support for laws concerning mental illness. In his proposals for such laws [START_REF] Forel | Zum Entwurf eines schweizerischen Irrengesetzes[END_REF], he made some remarkable statements, speaking out against the miserable conditions at that time and making a plea for clarifi cation of the laws concerning admission to and release from the clinic. On the other hand, the same article contains statements which could have led to just this sort of abuse; for example, he writes: 'Vice versa, an abnormal person can be a veritable horror, possessing the worst criminal characteristics and bringing torment to his surroundings, without coming into confl ict with the law. Such a "moral imbecile" belongs in a mental asylum which we recommend.' Astonishingly, in 1898 at the age of 50, Forel resigned from his post as Professor at the University of Zürich and as the Director of the clinic. He wrote about this in his autobiography:

A voice in my head was screaming to the psychiatrist, 'come out from behind your walls and tell the public the truth -study abnormalities of the soul outside the mental asylum. You must become an apostle of truth. What is the point then of remaining forever in closed mental institutions looking after the ruins of lost souls, victims of mankind's misunderstanding, while allowing the cause of such miserable circumstances to continue to fl ourish? That is cowardice!' Social hygiene demands a complete reassessment of our attitudes, tackling the problem at its roots and, above all, creating a rational, selective and humane system of reproduction … It occurred to me that here was a marvellous opening in the fi eld of social hygiene which, under the guise of a false morality, had until now been annexed by various religions and beliefs. [START_REF] Forel | Rückblick auf mein Leben[END_REF] In this context Forel mentions three important issues.

There are still three matters which interest me: fi rst of all women's issues, the subjugation of women by men, a unique situation in the whole of the animal kingdom. For this cause, I became a zealous apostle of women's right to vote, of women's rights in general. Further, the question of a world language, a language which would increase mutual understanding … Finally, the question of the human race itself. Which race is useful for the continuation of mankind and which is not? And if these lowest races are useless, how we should gradually eliminate them. [START_REF] Forel | Rückblick auf mein Leben[END_REF] Forel's main ideas The main points and principles which were central for Forel, to which he held fast and which motivated and formed the structure of his thinking, are as follows.

1. The monistic view, based on the idea of mankind and nature as one, as in the unity of body and soul; as Forel put it, 'the living brain and the soul are one and the same' [START_REF] Forel | Zum Begriff des Monismus[END_REF]. He was also a founding member of the German monistic order; Ernst Haeckel tried unsuccessfully to persuade him to become its president.

2. Determinism: everything is subject to the same law of nature which then determines what follows. From this perspective Forel contested freedom of will and, as a consequence, the sentencing of the guilty.

(His standpoint in this matter is very close to that of some of today's neuroscientists.) 3. Darwin's theory of evolution, above all its re-interpretation as social Darwinism, i.e., natural selection -but no longer as meant by Darwin himself -is transferred to human society; social and cultural processes are seen as 'natural'. Biological inequality, i.e., variations within a species, on which natural selection is based, were now, according to social Darwinism, biased and so became: the unequal value of life [START_REF] Wuketits | Evolutionstheorie kontra Sozialdarwinismus[END_REF].

Forel attempted to summarize these principles into a world-view based on natural science. He turned almost completely against every form of metaphysical thinking, seeing himself as a follower of the Enlightenment -someone who did not wish to show any false consideration or pity. In summary: he stood for an ethic that was monistic or based on natural science, as did Eugen [START_REF] Bleuler | Die naturwissenschaftlichen Grundlagen der Ethik[END_REF].

Forel's position on eugenics

The expression 'eugenics' was coined by Francis [START_REF] Galton | Hereditary Genius: An Inquiry into its Laws and Consequences[END_REF]. The aim of eugenics was the improvement of the human race, through increasing the number of desired offspring (so-called positive eugenics) or by preventing/ avoiding undesirable offspring (so-called negative eugenics). Forel, like many of his contemporaries, had a fear of the degeneration of the cultured races and, according to his fundamental principles, agreement with and support of eugenics were easily understood. Forel's acceptance of the hereditary theory and his fear that mental illness would spread are already apparent in his lecture of 1880 and during the years following his offi cial appointment at Burghölzli. In the lecture, entitled 'The most important causes of mental illness and its prevention', he puts inheritance fi rst, referring to it as 'the enormity of the hereditary factor', which produces more people who are insane, thus passing on the illness through inheritance and 'resulting in a gradual degeneration of an ever-increasing part of the nation' [START_REF] Forel | Über die wichtigsten Ursachen der Geisteskrankheiten und deren zweckmässige Bekämpfung[END_REF].

He comments vividly on this mental degeneration:

It's rather strange -like one step forward and one step backward. In the Middle Ages those who were insane were tortured and killed, which is undoubtedly cruel. They were regarded as Pariahs, and eradication was seen as cleansing and reducing madness in society, whereas nowadays patients are generally treated with humanity and cared for, so as to cure and sustain them, thus contributing to the increase of madness through inheritance. [START_REF] Forel | Über die wichtigsten Ursachen der Geisteskrankheiten und deren zweckmässige Bekämpfung[END_REF] A few years later, Forel wrote a report on: 'Why, when and how are the insane kept in a mental asylum? Mental disturbance, the law, morals and the penal institutions', fi nishing with the following remark:

I will leave open the question of whether it is the best and most humane way to eradicate such disgusting specimens of human brain by painless death. Such as the question of preventing the reproduction of such criminals [sic]. These are immature but worthwhile considerations. [START_REF] Forel | Warum, wann und wie sperrt man Menschen in Irrenstalten ein?[END_REF] In comments such as this, he mentions euthanasia as a possibility. In the same report he mentions a female patient who was hospitalized for having a constant hacking cough which was interpreted as a sign of hysteria. Her treatment was to have her ovaries removed. [START_REF] Forel | Die vereinigten Staaten der Erde[END_REF] mentions this patient, among others, in his publication Die vereinigten Staaten der Erde. He writes: 'By 1885, without knowing the work of Galton, I had suggested negative eugenics, sometimes under the pretence of medical reasons, but in reality to prevent those disgusting species of mankind from reproducing. [START_REF] Forel | Die sexuelle Frage[END_REF] points to other eugenic measures in his most successful book Die sexuelle Frage:

The most eager and enthusiastic fi ghters for reform (more recently, Rüdin) who suggested castration in such cases [here referring to alcoholic parents] have provoked screams of outrage. The over-sensitive, cultured man of today cannot think such thoughts, whereas many ancient nations and national leaders kept eunuchs for convenience, to have a harmless servant for their wives, and they would behead or hang anyone without a second thought, as the followers of Islam do nowadays. Even the Pope himself kept castrated men as descant singers for church choirs. For this purpose boys were castrated in their childhood … Nevertheless, recently and now, castration is regarded as a way of healing all manner of illness in men and women, especially hysteria in women … I quite openly admit to agreeing to the castration of a disgusting, psychically ill patient in my hospital, who had complained about a pain in his genitals. He himself wanted this castration while I clearly thought of it in terms of preventing him from having children rather than treating his condition. I also allowed the removal of the ovaries of a hysterical 14-year-old girl, whose mother and grandmother were both prostitutes and who gave herself to every boy on the street, because I wished to prevent this misery from being perpetuated. At that time it was the fashion to use castration to cure cases of hysteria, and I used this pretence although, in reality, it was done purely for social reasons.

In 1910 Forel gave a lecture, later published, on 'Malthusianism or eugenics' at a Neo-malthusianism Congress in Holland [START_REF] Forel | Malthusianismus oder Eugenik?[END_REF]. In dealing with the problem of over-population, Forel gave a critical appraisal of Malthus' thesis and Neo-Malthusianism. This publication contains many important connections between racism and eugenics which were, typically, made by Forel and his contemporaries. Thus, for example, he says:

Mankind, as it is today, has gradually evolved from a natural primitive state following the laws of evolution and the fi ght for existence. However there are colossal differences. There are peoples among us who appear, zoologically speaking, to belong to the species of Homo sapiens because they have mixed with civilized man and produced offspring. These creatures, however, possess such inferior mental faculties that they remain at a lower cultural level. Their brains are much smaller than ours and so on. Two such peoples are the Weddas in Ceylon and Stanley's Pygmies, the Akkas, in the Congo Basin. These are not a danger for our race as they are doomed anyway. Considerably more danger is posed by particular races, above all the negroes, who are physically strong and robust, extraordinarily fertile, but mentally inferior, who have learned to adapt to our culture extremely well. When they have adapted to our culture they corrupt it and our race through sloth, lack of ability and by creating such awful, mixed races as the Mulates. By carefully observing the situation in the southern states of the USA it is easy to be convinced how negatively the negro element, as it increases, affects our culture. [START_REF] Forel | Malthusianismus oder Eugenik?[END_REF] Forel's boundaries concerning race differed from those stated later by the National Socialists, for example, and he did not despise every social mixture; furthermore, for him, the pure Arian race did not exist. For instance, Forel wrote in a letter to Dr Rösler, dated 30 April 1912:

Our cultural nations are an utterly artifi cial product, created by wars and what the conquerors imposed on the conquered. The Swiss are made up of Germans, Romans, Celts, etc. Similarly Germany and France, etc., not to mention North America, which comprises a collection of all possible races. It is a deeply-rooted, scientifi c lie when, for example, the German nation defi nes itself as being 'purely German'. It is full of Celtic, Slavic and mixed blood. Therefore I utterly reject this artifi cially produced nationalism, not only of the Germans but of all peoples. It is damaging, as it emphasizes what is different and inflames war, hate and self-righteous superiority … Just as the Swiss 'William Tell' patriotism is questionable … Of course, one should not misunderstand me. In no way do I doubt true racial differences, according to natural science, nor do I agree with mixing in inferior races such as negroes. However it is not true, in fact absolutely untrue, to speak of natural laws concerning the boundaries of our national cultures. [START_REF] Forel | Briefe = Correspondance: 1864-1927[END_REF] Forel continued to believe in eugenics or selective human reproduction, to which he referred with pride. Nonetheless, it is remarkable that in 1910, after the discovery of sterilization, [START_REF] Forel | Malthusianismus oder Eugenik?[END_REF] rejected it in some cases: he regarded the procedure as a serious step and pointed out that he had refused many appeals for sterilization by healthy patients, while agreeing in cases where reproduction appeared to have a harmful social effect. Indeed, he emphasized that:

[T]he sterilization of the wretched, the lazy, and the bad in such a society will be the natural codex of social duty For the insane and for criminals there will be a law to enforce such sterilization, even against one's will. Furthermore, it will be possible to separate love and the need for sexual satisfaction from reproduction because it will be seen that the highest of mankind's duties lies in proper eugenic procreation … There is no need to add that an integral social reform, which cuts off the vital life-giving artery to our present materialism (Mammonismus), is necessary in order to allow a sensible, scientifi c (not dogmatic) social democracy to solve the eugenic problem … Then a stupid, ignorant, degenerate mental and physical proletariat, which in its unconscious simplicity reproduces like rabbits and thus fouls our society like a harmful pest, will no longer exist. [START_REF] Forel | Malthusianismus oder Eugenik?[END_REF] Clearly, there can be no doubt as to Forel's eugenic ideas and eugenically orientated activities. In spite of seeing himself as a down-to-earth and impartial natural scientist, Forel had no empirical or scientifi c basis for accepting this idea of hereditary and had certainly done no research whatsoever in this fi eld. Nevertheless, he put forward the degeneration theory and the paradigms of inheritance, as did most of the other psychiatrists of his time. Furthermore, his idea, which he called the 'Blastophthoria' -that the germ plasma is affected by alcohol, with the corresponding hereditary consequenceswas a complete misconception. He boasted about individual castrations and sterilizations, to which he often referred, in various contexts, as mentioned above. In his public lectures and publications Forel supported eugenics and he had a strong effect on his audience and readers. However, in the university and scientifi c milieu, due to the lack of his own research, he was unimportant, in contrast to Ernst Rüdin. In fact he was not involved in the development of genetics and a scientifi cally-infl uenced eugenics, which was the foundation for the enormous number of enforced sterilizations that subsequently took place [START_REF] Kuechenhoff | Eugenik -wissenschaftlich verbrämte Gewalt gegen Psychischkranke[END_REF].


Christian Gutmann
email: philipp.gutmann@medizin.uni-halle.de

Keywords: forensic psychiatry, Germany, personality disorders, psychiatry, psychopathy, 19th century

, in which he tried to bring together critical Kantian philosophy and Christian conviction. In

Introduction

When looking at the history of medicine and psychiatry, it is obvious that certain psychopathological phenomena have been well known since ancient times. The ancient physicians were familiar with phenomena such as delusions or hallucinations. Galen, for instance, described symptoms of a psychosis which he called 'paraphrosyne' (Roccatagliata, 1986: 201). Since the beginning of scientifi c psychiatry 200 years ago, many authors, for example Kahlbaum and Kraepelin, have attempted to classify psychiatric disorders and have tried to defi ne nosological and aetiological concepts, but these were often incoherent.

However, there is no doubt about the pathological state of these phenomena; because, in general, they can be clearly separated from conditions belonging to the domain of normal psychology.

Yet physicians have always been aware that there were individuals with remarkable mental abnormalities which obviously cannot be included among the severe mental disorders and do not resemble symptoms of a psychosis, but which nevertheless seriously affected these individuals and their environment and could not be described within the boundaries of normal psychology. We are referring to individuals whose personality differs signifi cantly from the average personality, to an extent that their personality can no longer be described as normal. Obviously some individuals, by adolescence or young adulthood, show distinctive behavioural characteristics, but do not suffer from a psychosis. Many attempts have been made to describe these features more exactly, espe-cially after the introduction of scientifi c psychiatry. Pinel for instance intro-duced the term 'manie sans délire'. Later, Prichard ('moral insanity') and Lombroso ('delinquente nato') described certain criminal personality types (see Berrios, 1996: 426;Fiedler, 1994: 13 ff.).

At the end of the nineteenth century, as the concept of what we now call personality disorders developed further, a physician called Julius Ludwig August Koch was becoming well known. Koch was not working at one of the numerous university hospitals, which were springing up all over Germany at that time. Instead, he was the physician heading a mental hospital in a small town called Zwiefalten in Württemberg, Germany. In the early 1890s, Koch published a monograph in three volumes entitled Die psychopathischen Minderwertigkeiten (Psychopathic Inferiorities; [START_REF] Koch | Die psychopathischen Minderwertigkeiten[END_REF], which would become a classic in the world of psychiatry. So who was this man, about whom little is known, even by psychiatrists with an interest in history? What was the personal, mental and scientifi c background of his work? How can we classify Koch's text today, more than 100 years after it was written? By describing Koch's life and work, I hope to provide an answer to these questions.

Biographical notes

Julius Ludwig August Koch (Fig. 1) was born on 4 December 1841 in Laichingen in Württemberg, Germany. There had been several teachers in his father's family, including his grandfather who was a headmaster of a school in Hamburg. According to his biographers, Koch's father had a doctoral degree in medicine and philosophy and a broad educational and cultural background, which may have been of great signifi cance to Koch's own development. Koch's father's family came from northern Germany and his mother's family, in which there had been many priests, came from Württemberg in southern Germany.

Koch was the oldest son and was originally going to become a priest or a teacher; however, because he caught typhus, he failed a critical examinationthe so-called Landexamen. Instead, he worked as a chemist from 1857 to 1861. In order to qualify in medicine and then help his father, who worked as a general practitioner and headed his own private insane asylum, Koch passed his Reifeprüfung (fi nal secondaryschool examinations, which made it possible for him to study at university) in 1863. From 1863 to 1867, he studied medicine in Tübingen, Germany, and travelled to such places as Prague and Berlin (where he met Griesinger). Later, he joined his father in Laichingen and began working as a general practitioner. In 1870 he married Julie Herwig, a priest's daughter. He then became an assistant doctor at the private hospital in Göppingen. From July 1874 until February 1898, he headed the Württembergische Staatsirrenanstalt, the state insane asylum (Fig. 2). Because of severe heart and lung disease, Koch retired in 1898 and moved to Cannstadt. He returned to Zwiefalten after his eldest son (Koch had three children) became senior physician in the Zwiefalten asylum. After a long period of suffering, Koch died on 25 June 1908 at the age of 67.

According to biographers (Gaupp, 1924: 195;[START_REF] Römer | [END_REF] 1004 ff.), Koch's father was very important in his development. From his youth, Koch was used to having contact with the mentally ill. When he became head of the asylum in Zwiefalten, he worked very hard to expand the hospital. In 1874 the average number of patients was about 190, and by the time Koch retired in 1898 the number had increased to 560. During this time, he was practically without any competent support because young physicians stayed in his hospital only until they were suffi ciently educated in psychiatry to move on to other positions.

Koch had a wide range of interests. He studied the local natural history and published a paper on leaf lichens in the Zwiefalten area. He was also interested in the arts, especially poetry, and published his own poems, initially under the pseudonym 'Fredelik', later under his own name. As far as we know, Koch was a fairly reserved man. Although he was quite successful in life and won recognition, he 'could also keep silent in circumstances, in which he was undoubtedly treated unfairly, and in which most people would have retaliated forcibly. Basically this character trait is associated with his religious conviction' [START_REF] Römer | [END_REF](Römer, : 1007)), which also impacted his family life.

Although deeply religious, Koch was nevertheless fascinated by the natural sciences. His efforts to keep these two areas separate were, in the end, unsuccessful, and this may partly explain Koch's contradictory character. He often seemed to be full of scruples. As [START_REF] Römer | [END_REF]Römer ( : 1008) ) suggested:

He was aware that he himself was not free from such doubts, and he was honest enough to admit this to himself and to others where such a confession seemed advisable to him. Some traits of his image of the hereditary burden (angeborene Belastung) obviously arose from his neutral self-judgement and were recognized by him as signifi cant for human life.

Gaupp, who for a short time worked under Koch's guidance in Zwiefalten, gave similar descriptions of Koch's character. He described Koch as an 'impressive and amiable personality of great gentleness, broad and deep education, with a very religiously-oriented basis to his character, and he was seriously concerned about religious problems in his later years' (Gaupp, 1924: 196). Gaupp also noted Koch's markedly Christian attitude, which seemed to pervade him:

He fi rmly believed in the revelation of God. His plain devoutness and his rich and vivid mind especially were expressed in his religious poems … As a medical minister to many people, Koch emphasized the curative value of religious beliefs, 'the certain confi dence' that arises from the certainty of belief, especially for those suffering mentally. With subtle humour and with impressive certainty he was successful in infl uencing his patients by suggestion; the seriousness of his own mind, with an inclination to compulsive ideas, gave Koch an empathy for the inner needs and imbalances of the psychopathic inferiorities (psychopathischen Minderwertigkeiten), which he portrayed with particular affection.

Koch seems to have been a contradictory, perhaps scrupulous, but in any case, deeply religious person, and one cannot go far wrong in assuming that, by keeping a close eye on himself, he was able to recognize some of the traits he described in the 'Psychopathic Inferiorities'.

Philosophical and religious background

Before Koch published his most important psychiatric works in the last two decades of the nineteenth century, he had studied philosophy deeply and had defi ned his own position in several publications. His fi rst philosophical work Erkenntnistheoretische Untersuchungen (Epistemological Investigations) was published in 1883, and Grundriß der Philosophie (Compendium of Philosophy) in 1884. Only two years later, Koch published his main philosophical work: Die Wirklichkeit und ihre Erkenntnis. Eine systematische Erörterung und kritisch vergleichende Untersuchung der Hauptgegenstände der Philosophie (Reality and its Knowledge. A Systematic Discussion and Critical Comparison and Investigation of the Main Topics of Philosophy; [START_REF] Koch | Die Wirklichkeit und ihre Erkenntnis. Eine systematische Erörterung und kritisch vergleichende Untersuchung der Hauptgegenstände der Philosophie[END_REF]. This was his most extensive and systematic explanation of his philosophical point of view, and he himself called this text the most mature of his philosophical works. Thus, my summary of Koch's philosophy is based mainly on the insights contained in this work.

In this book, Koch tried to reconcile two points of view which were central to his intellectual development: fi rst, the Christian faith, which was always the basis of his thinking, and second, Immanuel Kant's critical philosophy. In a careful reading of Koch's philosophical works, it quickly becomes clear that in any confl ict between the two, the former always had the upper hand over the latter.

With regard to Immanuel Kant, Koch believed that only one's own existence and imagination (Vorstellung) of the world were certain elements of one's consciousness, and that the reality of the external world could not be proven in a strict sense. However, Koch also rejected the contradictory position of radical scepticism, which refuted the existence of any external world. For Koch it was important to recognize one's 'sense and cohesion of the world', which itself was dependent upon the elements of one's own consciousness. Koch strictly rejected -as he called it -'subjective phenomenalism'.

Koch criticized Kant for denying the existence of 'extra-sensory perception' (übersinnliche Erfahrung). Kant had not examined the origin of 'the world above us' or of a 'free mind' (freier Geist). Thus, Koch wanted to defend two central issues of his thinking: fi rst, the belief in God, and, second, his indeterministic conviction that the human mind was free and independent of body and soul, which was especially relevant to forensic-psychiatric issues. Koch also wanted to overcome the Kantian distinction of the 'thing itself' (Ding an sich) and its 'appearance' (Erscheinung). He favoured an epistemological theory of correspondence (adaequatio intellectus et rei) when he stated that world and subject determine one another (Koch, 1886: 162).

Again and again, Koch emphasized that the reality of the external world was nothing but 'faith' (Koch, 1886: 230). Solipsism for him was not logically refutable. Using this point of view, he complained that belief in a real human mind and the 'world above us' was as legitimate as belief in the reality of the external world. On the other hand, Koch argued as a natural scientist: he believed that the perceivable world operated according to mechanistic laws. For him, body and soul belonged to the material world, which was in contrast to the mind (Geist). The soul operated according to the same mechanistic laws as the material world; therefore, in the soul there was -in contrast to the mind -no freedom. The appearance of the mind should be independent from that of the soul and body. Indeed, the existence of the mind could not be proven; however, there were good reasons to assume its existence. Through the mind, not only does freedom exist, but it is also a 'moral claim by God' (sittliche Anforderung durch Gott). This claim of morality accrued from religion and fi nally from God. Koch rejected every form of materialism or atheism, which lacked any ethical power for life. With regard to the mental and material double existence of man, Koch was a dualist when he wrote that the 'human mind is independent from the existence of the body composed of matter; the matter composing the body, however, is independent of the mind'. Koch regarded mind and matter as similarly indestructible. In his dualistic view, he left open the question of how the mind and body interact: 'We don't know, and we shall never fi nd out, in which way the impact of the mind to the body and vice versa comes about and is made' (Koch, 1886: 271).

Koch said that we experience a 'world above us' as a sensory external world or a human mind. According to him, the existence of this 'higher world' was justifi ed because only then is there a possibility of moral retaliation after the individual's death. Koch assumed the existence of a creative God. Without arguing in detail, he posited 'great theism': the doctrine which states that the world was created 'by a personal God from nothing'.

He was concerned about the relationship between philosophy and religion, holding the latter as more fundamental. In fact, Koch separated the two disciplines: philosophy should be without presuppositions, whereas religion should be believed in because of experiences which were evident in themselves without any inquiry. He thought that only through religion is one capable of realizing a 'true' view of the world. Philosophical positions which contradicted religion were dangerous: 'When in a Christian nation philosophical trends against the Christian faith get the upper hand, the people will necessarily face severe affl ictions and dangers' (Koch, 1886: 353).

When looking at Koch's philosophical work as a whole, it becomes clear that the Christian faith is the ultimate basis of his thinking, which cannot be questioned by any philosophical argument. One example illustrates how dogmatic his way of thinking was: as long as he discussed questions concerning the world of 'appearances' (Erscheinungen), e.g., the world outside us, he used arguments based on Kant to emphasize his point of view. But, as soon as he left the world of the Erscheinungen and wrote about 'free will' or the 'world above us', he appealed to his faith or incontrovertible evidence. For him, the simple fact that mankind was confronted with moral challenges provided the proof for an existence of God. He assumed that every man had a feeling of a 'world above us', which he believed to be a monotheistic one. All these postulates were so evident to Koch that he considered a more detailed inquiry unnecessary. In his main philosophical work, [START_REF] Koch | Die Wirklichkeit und ihre Erkenntnis. Eine systematische Erörterung und kritisch vergleichende Untersuchung der Hauptgegenstände der Philosophie[END_REF] expressed his conviction that the reality of God is unquestionable, because otherwise the injustices of this world could not be compensated for. Witte was probably right to regard Koch's philosophy and especially its religious traits as a 'homespun philosophy' (hausbackenes Bekenntnis) (Koch, 1886: 398).

All in all, Koch's thinking seemed to be quite dogmatic: he believed that every philosophy not consistent with the Christian faith was dangerous, and he predicted that every nation in which atheism was predominant would suffer disaster. Koch might also have been expected to criticize Nietzsche's philosophy, but names or terms related to Nietzsche were not found in his works. Overall, the impression prevails that Koch's thinking -although dealing seriously with philosophical questions -was limited by his fundamentally Christian view of life.

The psychiatric works

Koch's psychiatric nosological system Koch's fi rst written work was his dissertation, which he wrote during his medical studies in Tübingen, Germany (1863-67), Über das Hirn eines Buschweibes (On the Brain of a Bushwoman; [START_REF] Koch | Über das Hirn eines Buschweibes[END_REF], which may sound rather peculiar today. In 1878 he published an epidemiological work: Die Statistik der Geisteskrankheiten in Württemberg und der Geisteskrankheiten überhaupt (Statistical Data on Insanity in Württemberg and on Insanity in General), in which he demonstrated why the growing number of inmates in lunatic asylums at that time did not constitute a growing proportion of insanity in the population. Later, Koch published the philosophical works mentioned above and, in 1888, he presented a description of mental disorders Kurzgefaßter Leitfaden der Psychiatrie (see [START_REF] Koch | Kurzgefaßter Leitfaden der Psychiatrie. Mit Rücksichtnahme auf die Bedürfnisse der Studirenden, der practischen Aerzte und der Gerichtsärzte[END_REF]. He developed his nosological system in this book and in some other publications about the same time, including Specielle Diagnostik der Psychosen [START_REF] Koch | Specielle Diagnostik der Psychosen. Kurz dargestellt[END_REF] and 'Diagnostischer Überblick über die Psychosen' in Börners Reichsmedizinalkalender [START_REF] Koch | Diagnostischer Überblick über die Psychosen[END_REF] and following years). The classifi cation of mental disorders presented by Koch in his Leitfaden (published the year before Die psychopathischen Minderwertigkeiten) remained the basis of his psychopathology, so some of its main points will be mentioned here. These two books are diffi cult to understand, because Koch used several terms which were contradictory to normal usage. Therefore, in order to prevent misunderstandings, I would like to make some introductory remarks on his terminology.

Koch differentiated between mental disease (Geisteskrankheit) and insanity (Irrsinn), where insanity is the narrower term. Mental disease also comprised idiocy (Idiotie), which conforms to today's mental retardation. It was also unusual that he used the terms 'disposition' (Disposition), 'burden' (Belastung) and 'degeneration' (Degeneration) for several degrees of psychopathic inferiority. However, in his opinion, this was only a gradual differentiation, not a categorical one. Another unusual term that he used was 'idiopathic' disorder, which he assumed to be a disorder in patients who had been totally healthy before.

For Koch, the word 'psychopathy' had a very broad meaning. It was more or less a synonym for mental abnormity in general and comprised the psychoses, as well as his psychopathic inferiorities. Also his use of the word 'organic' was misleading. Sometimes he wrote about 'organic psychoses' and meant the exogenic disorders due to brain disorders; and sometimes he stated that the psychopathic inferiorities could also be caused by brain disorders, and called them 'functional organic deviations' (organische Abweichungen funktioneller Art). Despite his undeniable efforts to achieve an unambiguous and systematic classifi cation of mental disorders, there have always been misunderstandings due to these terminological ambiguities, and even his contemporaries had some diffi culty in reading his works.

In his psychiatric-nosological system, Koch differentiated three main units: in the fi rst group were the 'isolated psychopathic phenomena and their combination in psychopathic states'; the second group comprised the psychopathic inferiorities; and the third group described the psychoses, which Koch divided into 'idiocy' and 'insanity'. Insanity was then subdivided into idiopathic, constitutional, and organic psychoses. Also the 'transitory psychopathic states' described by him can be assigned to psychoses.

According to Koch, the fi rst group -the independent elementary mental abnormalities -comprised, for example, isolated hallucinations and compulsive phenomena. These could occur in the mentally healthy, as well as in the somatically and mentally ill. The latter seems to be problematic, because it is difficult to differentiate between isolated hallucinations and schizophrenia (according to today's classifi cation).

The second group -the psychopathic inferiorities -was the subject of Koch's three-volume monograph which will be dealt with separately below.

Koch's third group -the psychoses -also comprised states of mental retardation ('idiocy'). Koch preferred a differentiation into 'apathic' and 'erethic' idiocy rather than a graduation between them. The term 'insanity' comprises the 'idiopathic psychoses' (named by Koch), which include melancholia, raving madness, secondary idiocy, hallucinatory confusion and primary idiopathic idiocy. 'Constitutional psychoses' are independent psychoses due to hereditary or acquired constitutional inferiorities of the nervous system. This is a very heterogeneous group of mental anomalies, such as paranoia, moral insanity, hypochondriac, hysterical or epileptical insanity or litigious paranoia. Under the 'organic psychoses', Koch also subsumed fairly heterogeneous syndromes, such as catatonia, delirium acutum, paralytic, luetic and alcoholistic idiocy and old age idiocy.

The last entity, according to Koch, were the transitory psychopathic states; here he included, for instance, mania transitoria, transitory stupor or raptus melancholicus, and also states with restricted awareness -comparable to today's organic cerebral psychosyndromes.

I cannot discuss these differences in detail here, but anyone interested would fi nd it useful to read Koch's works, in spite of the problems due to the unusual nomenclature and systematics he used. These may be diffi cult for a presentday reader, who is familiar with Möbius's differentiation into endogenous and exogenous psychoses, and with the differentiation of the endogenous psychoses into manic-depressive illness (or bipolar-affective disorder) and dementia praecox (or schizophrenia). Nevertheless it is worth the effort to explore Koch's publications. Those who would like to learn something about the difference between compulsive and delusional ideas, for instance, can fi nd an exact differential diagnosis. In Die psychopathischen Minderwertigkeiten (see below), Koch presented a considerable number of patient histories which are worth reading and which add interest to the rather heavy text.

Die psychopathischen Minderwertigkeiten

Koch's main work, which has ensured him a lasting place in the history of psychiatry, is without any doubt his three-volume 'Psychopathic Inferiorities' published in 1891-93. I would like to present a general summary.

In his introductory remarks, Koch (1891-93, I: 1) outlines the main topics he will describe:

The term 'psychopathic inferiorities' comprises all abnormalities -either hereditary or acquired -which infl uence a human's personal life, but which do not constitute -even in their worst cases -mental illnesses, although the persons suffering from them do not seem to be of a sound mind and sound physical capabilities.

The fi rst volume deals with the permanent psychopathic inferiorities (in contrast to the non-permanent ones, which form another category). These permanent psychopathic inferiorities are classifi ed into three main groups: the hereditary ones, the acquired ones and a mixture of both. Koch describes in detail the previously-mentioned three stages, which more or less seem to be degrees of insanity: disposition, burden and degeneration; where, the fi rst one can change to normality, and the last one to insanity. By Koch's time, these three terms were contradictory to the usual understanding of the words.

Apparently infl uenced by the views of Lombroso (in Italy) and Kurella (in Germany), Koch describes the term 'hereditary psychopathic inferiorities' as several physical signs of degeneration, which can also be found in healthy people (for example, a 'receding forehead', 'asymmetries in skull and face' or a 'fl attened occiput').

The mildest form of hereditary psychopathic inferiorities -'hereditary psychopathic disposition' -is, according to Koch, characterized by 'mental tenderness', which is sometimes accompanied by physical tenderness. An indicator of such a disposition can be strong homesickness in adolescents and young adults. The next stage -'hereditary burden' -shows symptoms such as 'irritable weakness', 'increased mental irritability', 'disharmonious character' or 'self-centred thinking and feeling'. In a separate chapter, Koch describes compulsive disorders, which he differentiates from psychotic experiences. Patients with compulsive disorders understand and accept the inanity of their compulsive thinking or acting, whereas psychotic patients do not. Koch also points out that compulsive disorders are diffi cult to treat and that they can occur together with other mental disorders, such as melancholia or psychoses.

The group of 'hereditary psychopathic degenerations' comprises disorders with symptoms of stress and also of 'mental weakness'. This mental weakness can be an intellectual, moral or general one. Koch differentiates further. For instance, in patients with moral weakness, he distinguishes an active type from a passive type. The active type shows a drive towards bad behaviour coming from within, whereas the passive type is characterized by low ethical standards. However, it is always necessary that the general symptoms of psychopathic inferiority are present, especially in a contradictory character.

Koch stresses the importance of caring for affected children and adults in special schools and institutions. He also believes that degenerate criminals are misplaced in prisons and jails, as well as in asylums. In a longer paragraph, Koch emphasizes the urgent necessity to set out in law the possibility of diminished responsibility, as the individuals suffering from this degeneration are not certifi ably insane (and thus not responsible for their actions), yet their free will and self-determination are limited.

Koch sees a greater likelihood of a psychosis developing in those with a psychopathic inferiority, for instance, a 'prisoner's insanity'. The psychopathically inferior are also more likely to develop a psychosis due to poisoning. The fi rst volume of this work ends with a fairly heterogeneous group of disorders which can develop on the basis of hereditary psychopathic inferiorities, including 'constitutional mania and melancholia', 'hysterical insanity' and 'litigious paranoia'. In general, Koch's 'hereditary psychopathic inferiorities' are quite close to today's personality disorders.

In the second volume, Koch depicts those psychopathic inferiorities acquired over the course of one's life; therefore, using today's terminology, these can mostly be termed exogenous. Koch specifi es a number of possible causes, which can also be combined in several ways. Due to these numerous differentiations, this volume is rather diffi cult to read and understand. Gaupp (1912: 232) stated quite bluntly: 'Here, Koch's terminology becomes a torture'. Once again, we fi nd Koch's trichotomy into disposition, burden and degeneration. For example, under the 'acquired psychopathic dispositions' he summarizes mild psycho-vegetative symptoms of fatigue.

In the following chapter, Koch sharply distinguishes his views on the 'acquired psychopathic burden' from Beard's concept of neurasthenia. In Beard's opinion, the term 'neurasthenia' comprises too many different forms. Ironically, Koch's own concept of psychopathic inferiorities could not escape this criticism either.

Koch describes, in extenso, hypochondriac, anxious, compulsive andaccording to modern concepts -somatoform phenomena. For some of the 'acquired psychopathic stresses', Koch postulates his own aetiology. For instance, he assumes that intoxication with morphine, cocaine, bromine or caffeine can be responsible for nervous states. In addition, Koch's works repeat the theory, which had been held for several hundred years, of the harmful infl uence of onanism; he wrote about an 'onanistic constitutionally infl uenced burden' (Koch, 1891-93, II: 187; see also [START_REF] Braun | Die Krankheit Onania. Körperangst und die Anfänge moderner Sexualität im 18. Jahrhundert[END_REF][START_REF] Gutmann | Zur Reifi zierung des Sexuellen im 19. Jahrhundert. Der Beginn einer Scientia sexualis[END_REF].

Koch was defi nitely aware of the fact that hereditary and acquired psychopathic inferiorities might be diffi cult to distinguish in practice. He postulates that the category of 'constitutionally infl uenced acquired psychopathic burden' arose from his wish for systematization, rather than a need to describe something that would be found in everyday life. He also distinguishes between 'general' and 'specifi c' inferiorities. Apart from these problematic nosological and systematic differentiations, one fi nds in this chapter many descriptions of symptoms and syndromes which are worth reading. Regarding the therapy of the 'acquired psychopathic burden', he seems rather sceptical about the possible benefi t of new chemical substances. He rejects hypnosis.

Finally, Koch discusses Morel's and Lombroso's views on degeneration, about which he is quite critical. He thinks that the hypothesis of the degeneration of mankind proceeding from inner necessity cannot be confi rmed. Apart from degeneration processes, Koch also sees processes of regeneration.

In his third volume, Koch fi rst describes the 'acquired psychopathic degeneration'. He depicts states of mental weakness after infections, illnesses of the brain, or after acute mental disorders. Here, too, he presents several sub-groups. However, he always has to admit that there are no clear boundaries, but rather transitions between the sub-groups.

At the end of the third volume, Koch mentions 'transient psychopathic inferiorities' and again describes a group of quite heterogeneous syndromes, from the aura of an epileptic or the intoxication of an alcohol addict to depressive moods accompanying physical indisposition. Koch subsumes all these physical features -what we now call exogenous mental syndromes -into a single term. By doing so, he lumps together totally different disorders, which is generally unacceptable.

Koch fi nishes with some forensic-psychiatric thoughts and calls for the introduction of 'diminished responsibility' into the criminal code and for the establishment of special institutions for these types of criminals.

Koch's signifi cance to the history of psychiatry Koch's signifi cance lies in his efforts to defi ne the large area between mental normality and the psychoses. However, the integration of various symptoms and syndromes into one single term -the 'psychopathic inferiorities' -soon proved to be too coarse, despite Koch's numerous sub-differentiations. Yet, Koch's defi nition of mental anomalies, apart from the mental disorders, remains valuable. We are justifi ed in calling Koch one of the main authors to prepare the ground for today's concept of personality disorders, and he is accordingly mentioned in various publications on the history of psychiatry (Berrios, 1996: 49;Fiedler, 1994: 14;Schneider, 1946: 5).

Although experts among Koch's contemporaries scarcely took any notice of him, some of his terms, such as 'psychopathic personality' or 'psychopathic constitution', were soon found in various textbooks. Koch had a bigger response among non-experts, especially in the educational sector. Together with a teacher and a school headmaster, he published a journal called Die Kinderfehler, which was later re-named the Zeitschrift für Kinderforschung. Also, among theologians and lawyers, his theses were soon heatedly discussed. Some of Koch's statements seem quite up-to-date: for example, his call for special institutions for those he believed to be the psychopathologically inferior criminal offenders, who should not only be punished but also treated. Nowadays, diminished criminal responsibility, in Koch's sense, can be found in the laws of some nations, and offenders with mental illnesses are treated in forensic psychiatric hospitals. Yet there is still a lack of special therapeutic treatment for those offenders who are criminally fully responsible, but are nevertheless mentally ill.

Koch's comments on free will and on determinism are really fascinating to read. These can be found in his psychiatric, as well as in his philosophical works. For present-day readers, it is revealing to compare the views of more than a hundred years ago with those held today: the arguments in the dispute about free will are very similar. If the author's name is not revealed, some passages in Koch's works can hardly be identifi ed as originating from a historical text, and could be mistaken for a contribution in the current debate on free will and neurosciences.