VOLKER ROELCKE

BIOLOGIZING SOCIAL FACTS: AN EARLY 20th CENTURY

DEBATE ON KRAEPELINS CONCEPTS OF CULTURE,
NEURASTHENIA, AND DEGENERATION

ABSTRACT. This paper uses an historical approach to elucidate two alternative modes of
conceptualizing the relation between social factors and psychological phenomena perceived
as pathological. The core features of Neo-Kraepelinian psychiatric nosology associated with
the introduction of DSM-III in 1980 were also at the center of a debate in early 20th century
Germany. The protagonists were Emil Kraepelin and Oswald Bumke. Kraepelins empirical
research selectively focused on somatic factors as independent variables, such as alcohol,
syphilitic infection, and heredity. The ensuing nosology marginalised social factors which
might contribute to the etiology and symptom formation of psychiatric conditions. For
Bumke, the disorders in question (including the category of neurasthenia) did not represent qualitative deviations from normal psychological states, but quantitative variations of
ubiquitous psychological functions caused by a multitude of somatic, psychological, and
social factors. The main arguments of the historical debate are reconstructed, with special
regard to the professional and political context. The paper illustrates the importance of
context-bound pre-scientific decisions for the process of formulating theoretical concepts
in psychiatry and related disciplines.

INTRODUCTION
Contemporary psychiatry is frequently characterised as Neo-Kraepelinian,
due to its recourse to Emil Kraepelins nosology and in particular his concept of the dichotomy of dementia praecox/schizophrenia and the affective
psychoses (Blashfield 1984; Colp 1995; Klerman 1978; Wilson 1993).
The core features of the Neo-Kraepelinian approach are conventionally
summed up as follows: (a) Psychiatry is a branch of medicine, utilizing the
same methodologies as scientific medicine; (b) there is a distinct boundary
between the normal and the sick; (c) there are discrete mental illnesses; (d)
the focus of psychiatry should be particularly on the biological aspects of
mental illness; (e) there should be an explicit and intentional concern with
diagnosis and classification (Blashfield 1984; Klerman 1978).
It is true that these features may be traced back to Kraepelins own
work. But the question may be posed whether present day psychiatrists
and researchers of related disciplines employing or critically evaluating

Culture, Medicine and Psychiatry 21: 383403, 1997.

c 1997 Kluwer Academic Publishers. Printed in the Netherlands.

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the concomitant concepts are aware of the complexity of Kraepelins

approach, and of some of the historical reasons which led to the hegemony
of his approach, rather than a competing one, at least in early 20th century
Germany. It is the argument of this paper that the success of Kraepelinian
notions and nosology is closely linked to his specific conception of the
relation between psychological and social phenomena, and the sphere of
biology.
In this essay, I intend to look into some of the presuppositions and implications of Kraepelins theories. To this end, I shall focus on a historical
debate on the category of neurasthenia, and on the notion of degeneration.
This debate foreshadows in a number of respects the discussions leading
to one of the turning-points in American psychiatry (and indeed modern
psychiatry in general), the formulation of DSM-III in 1980 (Sabshin 1990;
Wilson 1993). Furthermore, it illustrates the importance of pre-scientific
strategic decisions and implicit presuppositions for the process of formulating theoretical concepts in psychiatry, and more generally in medicine
and the behavioral sciences.
THE HISTORICAL CONTEXT
The historical debate in question took place between Emil Kraepelin
(18561926) and his follower Ernst Rudin (18741952) on the one
side, and Alfred Hoche (18651943) and Oswald Bumke (18771950)
on the other. Kraepelin, who held consecutive professorships in Dorpat,
Heidelberg and Munich, is usually ranked amongst the most influential
psychiatrists of the 20th century. Frequently, he is also considered one of
the founding fathers of transcultural psychiatry. Bumke was Kraepelins
successor in the chair of psychiatry at Munich University in 1924, while
Rudin succeeded Kraepelin in his function as head of the Deutsche
Forschungsanstalt fur Psychiatrie (German Research Institute for Psychiatry) which Kraepelin had founded in 1917. Hoche was, during the period
in question, professor of psychiatry at the University of Freiburg (Berrios
and Hauser 1988; Dening and Berrios 1991; Hoff 1994; Schimmelpennig
1993; Weber 1993).
In the first decade of the century, all the above named psychiatrists
entered the already ongoing debate about the relation between the supposed
increase in functional nervous disorders (or functional psychoses) and
the conditions of life in modern civilisation. Neurasthenia was the prime
example of these disorders (Radkau 1994). The concept of neurasthenia as
a discrete disease entity had been introduced by the American neurologist
George Miller Beard (18391883), who in his first monograph on the

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subject had postulated an etiological link between modern life and the
occurrence of the new disease (Beard 1880, 1881; Rosenberg 1962). As
Beard himself observed, his ideas had fallen on particularly fertile ground in
Germany (introduction to Beard 1884; for the situation in the USA: Gosling
1987). This was probably due both to an intrinsic compatibility between the
structure of his nosology and existing theories in the German psychiatric
tradition, as represented by Wilhelm Griesinger (18171868), Heinrich
Schule (18401916) and Richard von Krafft-Ebing (18401902), and to
a particular ambivalence among German professionals and the general
public towards what was perceived as modern culture or civilisation
(Radkau 1994). The translation of Beards monograph into German in 1881
was followed by an enormous literary output on neurasthenia and the age
of the nerves. As early as 1893, a Handbuch der Neurasthenie contained a
bibliography of 18 pages on the topic (Muller 1893). Almost all the authors
of these publications repeated and developed further Beards account of the
symptoms of nervousness, and his characterisation of life in the modern
world, albeit with a tendency to a more pessimistic evaluation of the
future development of civilisation than his. The underlying nosology was
usually based on symptomatology, and disease causation was conceived
in general as an interplay between varying predisposing and inducing
factors; specific causation of particular disorders was hardly regarded.
The idea of a necessary and specific cause (which is essential if one
is to have defined disease entities) was generally absent. Beard too had
conceptualised the conditions of modern life as inducing factors alongside
a number of predisposing conditions. To him, the difference between the
causation of neurasthenia and other disorders was merely quantitative,
civilisation or its perceived attributes scoring high amongst the inducing
factors.
KRAEPELINS NOSOLOGY
Kraepelins historical contribution to psychiatric nosology is usually seen
in his empirical research program which, via the analysis of large amounts
of patient follow-up data, resulted in the demarcation of the categories of
dementia praecox (later schizophrenia) and manic depressive insanity in
the 5th and 6th editions of his Textbook in 1896 and 1899 (Berrios and
Hauser 1988; Hoff 1994). This picture is in agreement with the high esteem
in which empirical research is held in 20th century science, and it shows the
basic principles of modern psychiatric classification as derived from and
built on sound empirical foundations. However, it misses an essential point
of historical reality: the strategic decision taken by Kraepelin before setting

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up his research program, and before delineating his famous nosological

categories.
This decision is documented even in one of Kraepelins earliest publications, the Compendium of 1883 (this was the first edition of the later
Lehrbuch [Textbook of Psychiatry]). The organising principles of the
Compendium show a complete break with tradition: drawing on theoretical
ideas set out by Karl Kahlbaum (18281899), Kraepelin reformulated the
structure of nosology by attempting to organise all disease entities according to their putative causation. Consequently, the first and most notable
chapter of the book is that on etiology, whereas in all previous textbooks
which Kraepelin himself mentions in the introduction, the passages on
causation are placed somewhere further towards the end, after extensive
discussions of general principles of psychiatric method, symptomatology,
and supposed elementary psychological functions (e.g. Emminghaus 1878;
Griesinger 1845; Krafft-Ebing 1879).
In addition, Kraepelin reorganised the intrinsic structure of etiology:
external causes, and amongst them somatic causes, were now placed first
in the chapter on general etiology. In contrast, one of the most widely read
textbooks of the era, by Krafft-Ebing, published in its first edition four
years before Kraepelins Compendium, represents the hitherto traditional
structure of the section on general etiology. This section is divided into: I.
Predisposing causes: 1. General predisposing causes (such as civilisation,
climate, gender, religion, marital status, professional and living conditions); 2. Individual predisposing causes (such as heredity and education);
and II. Accessory, or precipitating causes: 1. Psychological causes; 2.
Somatic causes (such as cerebral infections and trauma, internal diseases,
gynaecological diseases, pregnancy, etc.) (Krafft-Ebing 1879). Kraepelins
new structure of general etiology, emphasizing somatic causes, was thus
embedded in a reformulated nosology which postulated discrete disease
entities constituted by their putative causation.
From the outset, Kraepelin had declared that his central aim was to
create a nosology that would provide a basis for successful prognosis,
therapy, and prevention. Using the experimental design of contemporary laboratory psychology, and the principle of bacteriology as a model,
Kraepelin concluded that psychiatry could only develop an equally powerful approach if clinical features were sorted out and grouped together in
such a way that a common underlying cause could be assumed. In addition, this cause which was to be focused on as the organising principle
of nosology had to be accessible to manipulation in a way similar to the
germs identified by Louis Pasteur and Robert Koch (Roelcke 1996, 1997).

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As I have mentioned, this reformulated nosology was not a result of

empirical clinical research, but rather was based on an intentional decision
by Kraepelin to adopt by analogy the principles of two other disciplines:
experimental psychology and bacteriology. The explicit motivation for this
decision was to establish psychiatry as a truly medical discipline and to
abandon theories and practices which were derived from as Kraepelin
viewed it speculative philosophy (Kraepelin 1883, 1887). Kraepelin
took this decision in a historical situation where the established medical
disciplines, and in particular those based on laboratory science, were experiencing an enormous growth both in material resources and public support
in accordance with German imperial politics. In contrast, psychiatry was
not yet established as an academic discipline: around 1880, only very few
university departments of psychiatry existed, and within the curriculum of
the medical schools the subject became obligatory only in 1901 (Eulner
1970).
The nosology as outlined in the Compendium was as yet only programmatic in character. The actual disease categories described here were still
the conventional ones, constituted generally by their symptomatology. It
was only in the later editions of the textbook that the postulated disease
entities which had emerged from empirical research conformed to the
pre-empirically outlined categorical boundaries. They were the result of a
research strategy selectively directed towards assumed disease entities
which were constituted by specific causes and a distinct pathological
anatomy. It was only because no well enough developed methodology
existed to investigate these areas of postulated basic importance that
Kraepelin chose to look systematically into the clinical appearance of
the assumed entities. To this end, he sought to compile information on
symptomatology, family history, and the long-term course of the patients
condition. The long-term follow-up of patients was based on the system
of Zahlkarten (counting cards: semi-structured case summaries). The
preformulated headings of these cards directed the researchers attention
only to certain questions: the entry on putative causation, e.g., was subdivided into heredity and other causes, and no explicit space was given
for the patients own account of his biography or his family situation (a
Zahlkarte is depicted in Kraepelin 1983, appendix; cf. also Jablensky et al.
1993).
As a matter of fact, Kraepelins pre-empirical decision shaped not only
his further conceptualisations, but also the structure of institutionalised
discourse and practice in his department. For example, when Kraepelin
had taken over the chair of psychiatry in Munich in 1903, he organised
regular internal discussions and public seminars on a number of topics

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which he enumerates in his autobiographical notes: histopathology, questions of heredity and degeneration, metabolism and serology (Kraepelin
1983). These focuses of interest were the crystallisation points for the later
departments within the German Research Institute for Psychiatry, which
was founded in 1917 (Kraepelin 1983; Weber 1991).
As a result of the described pre-empirical decision and the ensuing
research strategy, the psychiatric tradition inaugurated by Kraepelin was
dominated by a somatic-biological perspective, whereas the biographicalpsychological and the socio-cultural dimensions were marginalised.
Psychopathological phenomena were conceived to be the expression of
discrete nosological entities, with specific somatic cause, clinical features,
and pathological anatomy.
NEURASTHENIA
What were the consequences of this nosology for Kraepelins conceptualisation of neurasthenia? In the Compendium of 1883, Kraepelin described
neurasthenia as one of the functional neuroses, all of which had in
common functional alterations of the nervous tissue. This was in agreement with the prevailing theory which assumed that these alterations were
material in character, but it was not yet possible to identify them with the
available methods.
In 1881, the German translation of Beards monograph had been
published, and as mentioned before in the following two decades,
publications on neurasthenia as the result of modern life became almost
a literary genre, elaborating on the influence of various social factors on
mind and body. Most of the distinguished neurologists and psychiatrists of
the era gave their own interpretation of nervous exhaustion, the disease
of modern civilisation. But in contrast to these elaborations of the social
factors associated with the condition, Kraepelin kept firmly to his program.
The result was that in the 5th edition of his Textbook (1896), neurasthenia
as a distinct entity had disappeared. Clinical phenomena which previously had been attributed to neurasthenia were now scattered abroad: they
only showed up as asides or subheadings in two newly constructed and
completely different disease categories: Entartungsirresein (insanity of
degeneration), and Erschopfungszustande (disorders of exhaustion) .
Whereas the first condition was according to Kraepelin due to degeneration, a particular form of heredity (see below), the second disorder was
conceived as being caused by physical exhaustion or mental excitation,
which in turn would have its effects by way of an intoxication through
the accumulation of the products of catabolism. The pace and irritations

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of modern life, and their psychological implications, are mentioned in

passing; but
since we shall not be able to remove these general causes, it is our task to make the coming
generations strong and resistant and to prepare them for the struggle for existence [Kampf
ums Dasein]. (Kraepelin 1896: 349)

Thus, the social causes of the condition are explicitly set aside, and intervention in the form of prevention is to concentrate on the (physical) strength
of the potentially affected individuals. This should be achieved by physical
exercise in youth, abstinence, and political measures to guide or restrict
marriages according to assumed hereditary disposition.
The dismantling of the category of neurasthenia was continued by
Kraepelin in an article published in 1902. Here, he conceded retaining
the label, if at all, for conditions of physical exhaustion with neurological
and psychopathological manifestations the disorders of exhaustion outlined in the textbook (Kraepelin 1902). Although other authors, arguing
from different points of view, also criticized the vague boundaries and the
inflationary use of the nosological category (Wessely 1990), none of them
had explicitly shrugged away the social dimensions in the causation and
symptom formation of the condition.
But Kraepelin even went one step further. Being himself concerned with
the ambivalences of life in a rapidly changing world, he began interpreting
behavior and institutions which did not correspond to his traditional outlook
on societal life as consequences of degeneration, i.e., of quasi-biological
laws. The first instances of this sort of interpretation can be identified in
the publications about his journey to south-east Asia in 1903, in which
he set out his ideas for a comparative psychiatry (Kraepelin 1904a and
1904b). In contrast to todays understanding of the term comparative
psychiatry which implies an investigation of the variations of psychological appearances and their conceptualisations as a function of different
cultural contexts, Kraepelin made considerable efforts to fit all phenomena
with which he was confronted into his own nosological categories which
implied a priority of biological over social variables. Thus, Kraepelin interpreted deviations from the clinical pictures with which he was familiar as
consequences of the different nutrition, climate, and racial attributes in
the region. For example, the scantiness of delusions in patients identified by Kraepelin as suffering from dementia praecox he attributed not to
obvious difficulties of communication (via an interpreter), but to a racially
determined deficiency of psychological differentiation of both the affected
individuals and their culture. Kraepelin also assumed that the peculiarities
of indigenous religion and culture might in the future better be understood
as expression of racial characteristics.

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In this view of Kraepelin, social variables had no place in the etiology

and nosology of psychiatry, but on the contrary were themselves more
and more seen as determined by biological processes. The interpretation
of social life in terms of Darwinian biology was, of course, not novel
at this time. In Germany, by the turn of the century, the ideas of Social
Darwinism had mainly been propagated by biologists, representatives of
hygiene, economists, and politicians (Weindling 1989). Within the psychiatric profession, Kraepelin was among the first to take up these arguments
and in particular to apply biologically based psychiatric categories not only
to individuals, but also to social groups and institutions. Furthermore, his
theoretical concepts had a decisive impact on the further development of
psychiatric theory and practice throughout the 20th century.
MODERN CULTURE AND DEGENERATION: THE DEBATE
The specific assumptions of Kraepelins approach to social phenomena
had also their consequences for his contribution to the ongoing debate on
the relation between life in modern society and the occurrence of functional neuroses initiated by Beard. Kraepelins contribution, formulated
in a paper Zur Entartungsfrage (On Degeneration, 1908) and in the
publications about his experiences abroad, marked a turning point in the
whole debate: It implied a major shift in the focus of concern, namely from
the social origins of a disease that affected individuals, to the biological
processes that threatened the collective culture or folk body.
Kraepelin identified a bundle of medically relevant features of modern
civilisation: The increased frequency of insanity including the functional
neuroses, an increase in the suicide rate, the decline in the birth rate,
and a rapid spread of sexual aberrations. The main thrust of Kraepelins
argument was to explain these characteristics as results of the process of
degeneration. The theory of degeneration as introduced into psychiatry
by Benedict Morel (18091873) postulated the existence of an original
healthy and moral state, and a progressive deterioration from generation
to generation due to harmful alteration of the germ material. There was
no specific pathology associated with the different stages of degeneration,
but rather a broad gamut of progressive symptoms and syndromes, including all sorts of psychopathological phenomena and antisocial behavior
(Dowbiggin 1991).
Kraepelin in particular emphasized the role played by alcohol and
syphilis as toxic agents to the germ. These two factors he conceived
as the main threat to the individuals, and, more important, to the nations
genetic pool. In contrast to Morel, Kraepelin (together with most of those

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of his contemporaries who adopted the theory of degeneration for their

conceptualisations) did not assume a necessary link between increasing
degeneration and decreasing fertility of the affected families. Whereas
according to Morel, degeneration would thus be a self-limiting process,
Kraepelin believed that the degenerated individuals were more likely to
contribute to the spread of the hereditary evil, with their alleged tendency to
uncontrolled and promiscuous sexual behavior and an inability to live within the rules of convention. The new serological method for the diagnosis
of syphilitic infection (only developed in 1906 by August Wassermann
and Albert Neisser) apparently confirmed Kraepelins already exisiting
assumption and worry about the high prevalence of the infection.
Thus, as perceived by Kraepelin, degeneration was a condition not
limited to a small segment of the population, but one which threatened an
ever-increasing proportion of the whole nation. This logic allowed him to
diagnose not only individuals but social groups or even the whole nation as
suffering from degenerative conditions. He arrived at the conclusion that to
counteract the undoubtedly threatening dangers, urgent measures had
to be taken. Since no efficient therapy was available, Kraepelin advocated
a preventive strategy: the fight against alcohol and syphilis, and sensible
racial hygiene (Kraepelin 1904b: 469). To assess the current state of
affairs first, large-scale investigations into questions of the epidemiology
and heredity of the degenerative disorders should be undertaken (Kraepelin
1908) a program later to be carried out in the German Institute for
Psychiatric Research. Welfare programs were seen by Kraepelin as highly
dubious since they secured the survival and longevity of individuals and
populations of low value and thus were likely to result in the deterioration
of the genetic pool, an idea he had already formulated in the Compendium
of 1883.
Kraepelins position was criticised by Alfred Hoche (Hoche 1910).
Hoche first of all questioned the statement that the general prevalence of
psychiatric disorders was increasing. He pointed out that the statistical data
only showed an increase in the number of patients admitted to asylums and
hospitals. This he interpreted not as an expression of rising prevalence in
the general population, but rather as a positive development: namely the
disappearance of prejudices against psychiatric institutions and services.
However, he continued, there might be indications of an increase in just
a section of the possible disease states, the nervous conditions, although
the available data did not allow a definite judgment. But even if such an
increase had really taken place, Hoche argued, this should be interpreted
as a short-term development due to the rapid changes in social structure
and technical possibilities which produced their own necessities. Of the

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future he was optimistic, trusting in the human ability to adapt, which

would allow the development of mechanisms to cope with and even profit
from the results of modern civilisation. As an example, he conceded that
syphilis represented a threat to the psychological health of both the affected
individual and his offspring. However, he added that this threat should not
be blamed on modern civilisation, and that rather it would be modern
scientific knowledge that, after identification of the infectious agent (by
Fritz Schaudinn and Erich Hoffmann in 1905), would provide the means
to prevent and treat the condition. Thus, he concluded, syphilis and similar
threats did not justify preventive legislative measures such as the restriction
of marriages.
A further argument advanced by Hoche was the general difficulty in
eliciting the causes of psychiatric disorders and therefore arriving at valid
conclusions, e.g. on questions of heredity. This argument was the corollary
of an earlier critical attack by Hoche against Kraepelins nosology: During
the national meeting of psychiatrists in Munich in 1906, he had pointed out
that the example of progressive paralysis had proven that a known specific
cause by no means allowed the prediction of a typical clinical picture,
as Kraepelin had postulated. And, complementarily, the clinical picture
of this disorder, which can mimic any of Kraepelins constructed disease
entities, did not enable an unequivocal deduction of its causation (Hoche
1906).
The reply to Hoches critique came from Ernst Rudin, Kraepelins pupil
and one of his closest colleagues. He had been an assistant of Kraepelin
in Heidelberg since 1900, and later in Munich. From 1909, he was a
consultant, and later deputy at the Munich Department of Psychiatry. In
1918 he became head of the Department of Genealogy and Demographics
at the German Research Institute for Psychiatry which had Kraepelin as
its director. Rudin also was among the proponents of racial hygiene in
Germany since its inception around the turn of the century, and later
became one of the dominant figures of Nazi psychiatry (Weber 1993;
Weindling 1989). As early as 1909, Rudin had written a favourable review
of Kraepelins article on degeneration for the Archiv fur Rassen- und
Gesellschaftsbiologie, the periodical of the German Association for Racial
Hygiene (Rudin 1909). After the publication of Hoches essay, Rudin
himself produced an extensive paper on the subject, again addressed to
the readers of the Archiv (Rudin 1910). Here, Rudin agrees with Hoches
criticism of the questionable value of available statistical material. This
on its own did not allow one to state that the prevalence of insanity had
increased. However, Rudin presents another argument to prove such an
increase: since we know the causes of insanity, he writes, we have only to

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find out whether one or more of these causative factors has increased due
to life in modern society. And indeed, among the (somatic) factors listed,
syphilitic infection and alcoholism were identified as steadily increasing
conditions, since modern urban life enhanced both promiscuous sexual
behavior and the temptations to and supply of alcohol.
Thus, if one accepted the particular propositions both in regard to
modern urban life and to the special method of logic, it was possible
to arrive at the conclusion that the prevalence of insanity had in fact
increased. This conclusion Rudin explicitly set against Hoches too optimistic arguments. As additional evidence to that already employed by
Hoche and Kraepelin, Rudin cited the increased rate of delinquency. He
proposed that criminal behavior originated from the same sort of underlying degenerative disposition as insanity, and that therefore an increase in
the rate of criminality proved via the increase of the common causation
the original assumption of the increased prevalence of insanity.
With regard to the supposed rise in sexual aberrations introduced by
Kraepelin into the debate, Rudin had already earlier propagated the thesis
that this represented the result of increasing hereditary pathology that
would prove to be harmful to the race (Rudin 1904). Also in another respect,
the prime concern with the benefit of the nation was clearly expressed.
Rudin attempted to turn Hoches argument about the more widespread
acceptance of psychiatric services against its author:
The tremendously careful nursing [of the diseased persons] can only have the practical
effect of prolonging the average life-span of the patients enormously and to increase their
proportion compared to the healthy population. (Rudin 1910: 728)

Since the valuable members of the race exhibit an apparently reduced

urge for procreation, the resulting gap is thus filled with
below-average material which the softened process of elimination [gemilderte Ausmerze]
leaves behind in the arena of humanitarian activity. (Rudin 1910: 741)

From this perspective, it was the psychiatrist (as pars pro toto of welfare
activities) who, after alcohol and syphilis, was responsible for the increased
prevalence of insanity and for the imminent degeneration of the nation.
At this point, the argument of the costs or the (financial) burden was
introduced to the debate an argument that proved to be of some consequence for the further story. The main conclusion of Rudins contribution
to this debate was to urge preventive racial hygienic measures in order
to alleviate the burden on the collective folk body. The implication is a
priority of the collective culture over the individual. This becomes clear
when Rudin deplores the exaggerated protection of individual interest,
and instead proposes furthering the interests of the race, or nation.

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Following this exchange, Oswald Bumke staged a full-scale in-depth

analysis of the notion of degeneration (Bumke 1912). Referring explicitly
to the earlier contributions by Kraepelin, Hoche, and Rudin, Bumke first of
all aimed at a thorough analysis of the conceptual and empirical conditions
underlying the proposition of nervous degeneration. As he explains, the
notion itself implies the deterioration of the species or at least a social
collective; according to him a questionable evaluation, since it implied a
value judgment about what might be good and bad qualities of the group
in question. The only critierion by which to establish a value judgment like
this from categories intrinsic to the discipline would be the ability of the
group to guarantee its own further existence.
He continues to analyse the supposedly relevant medical phenomena
identified by Kraepelin and Rudin with regard to their causation, dealing
with every single argument hitherto brought forward in the debate. Thus,
the decline of the birth rate cannot he argues simply be taken as result
of a vague decline of the will to procreation, or a biologically determined
failure of procreational strength, or of sexual aberrations explained in
turn by the quasi-biological category of degeneration. All too often, these
hypothetical explanations had been confused with observable facts.
And all available evidence on this matter pointed to the conclusion that
the decline was the result of an intentional restriction of the number of
offspring by an increasing number of individuals. Such a decision had
social origins and should not become biologized.
Bumke then confronts two separate strands of Rudins arguments with
each other and exposes their mutual contradiction. Rudin had postulated
that alcohol was, next to syphilitic infection, the factor contributing most
to degeneration. In another context, he had elaborated on the physical
vigour and health of the rural population who had not yet been exposed to
modern civilisation. Bumke first of all recalls that rural populations are not
at all a homogeneous group so that it might be questionable to generally
attribute to them better physical health. Further, he points to empirical
investigations which indicate that alcohol consumption is considerably
higher in rural areas than in urban surroundings. Therefore, either the
alleged degenerative effect of alcohol is not that dramatic (or does not
exist at all), or the proposition of the better health of rural people does not
withstand criticism.
Regarding the suicide rate, Bumke attempts to reconstruct a more
detailed picture from available statistical material than just that there has
been a simple rise. He draws attention to the reduced rates during times
of war and political upheavals, whereas all evidence indicated an increase
both in economic crises and in times of rapid economic growth. Further,

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considerable regional differences would make it at least very difficult to

diagnose a general increase and interpret it only according to one set of
allegedly ubiquitous valid explanations.
More generally, Bumke poses the question of whether the problem
of determining the prevalence and incidence of psychiatric disorders can
be solved at all, or whether in fact too many variables were involved,
starting with the demarcation of what is being looked for and what is being
counted. Here, in the context of the methodological problems involved
in establishing the epidemiology of insanity, Bumke refers to Hoches
critique of Kraepelins nosology (which Hoche had since developed further
in a paper that has become a classic; Hoche 1912): How could a sound
quantitative analysis be possible at all if the entities in question had yet to
be established, or at least empirically validated? Was there even sufficient
evidence for a strict demarcation of distinct nosological entities, or the
boundaries between different clinical conditions in particular in regard
to what Bumke called the functional psychoses (which included both the
functional neuroses and manic-depressive insanity)?
Bumke continued that, if there was any increase in the prevalence of
functional neuroses, the available empirical evidence strongly suggested
that this was due to the rapidly changing demands of the social and technical world and the accompanying changes of attitudes and behavior, which
then resulted in temporary overtaxing of psychological adaptation mechanisms. The disorders themselves did not represent a qualitative deviation
from normal psychological states as Kraepelins nosology and Rudins
subsequent research on the heredity of distinct disease entities presupposed
but only quantitative variations of psychological potentials which were
common to all members of the species (Bumke 1912a, b).
In conclusion, Bumke rejected the theory of degeneration as an explanatory model, and instead attempted to outline a multidimensional approach
to the etiology of the functional neuroses (in contrast to the somatic
psychoses following trauma, infection or disorders of metabolism).
According to Bumke, the phenomena which Kraepelin and his followers
assumed to be manifestations of hereditary degeneration were in fact the
results of social factors such as poor living conditions and sudden changes
in the social structure associated with rapid industrialisation and urbanisation. Bumke did not question the importance of hereditary factors in
the etiology of functional neuroses. He assumed that for each individual
they determined the quantitative range within which psychological reactions might occur, and that only extremes of these reactions due to external
stimuli resulted in symptom formation. But in regard to the conditions in
question, he rejected the assumption that there were qualitatively distinct

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entities which had their basis in heredity. Instead, he insisted that the
degree of the impact of the hereditary factors had to be evaluated in each
individual case and to be viewed together with external physical and
psychological distress. And to him, the available data suggested that both
the declining birth rate and the increasing prevalence of nervousness were
mainly due to the latter factors. He also argued that there was no evidence
of accumulating deterioration of the collective genetic pool as assumed
in particular by Rudin, as well as in an article which another pupil of
Kraepelin, Robert Gaupp, had published in 1909. Finally, in contrast to
Kraepelin and his followers, Bumke did not use the argument of the costs
for the public or of the threat to the folk body. Therefore, he did not see
any reason for the restriction of individual rights in the name of the nations
wellbeing, such as by legislation to prevent the marriage of degenerates
or to enforce compulsory sterilisation.
The first world war brought about a temporary break in the debate. The
defeat of imperial Germany, the revolutionary turmoils, and the perceived
impact of the treaty of Versailles resulted in an atmosphere of uncertainty
about the nations future.
In this historical situation, Kraepelin resumed the debate. Now, he
applied the notion of degeneration and derived psychiatric concepts not
only to the collection of medically relevant phenomena mentioned earlier
and their potential consequences, but also to the immediate political situation. In 1919, he devoted a lengthy article to contemporary issues in
public life from a psychiatrists point of view. In this, he diagnosed society
as suffering from hysteria, and in particular diagnosed the leftist leaders
of the short-lived Munich republic as psychopathic. The political developments had according to Kraepelin only come about as a result of
increasing deterioration of the collective hereditary disposition (Kraepelin
1919; Engstrom 1991). Similarly, in the same year, Gaupp talked about a
nervous breakdown of the nation and pathologized the revolutionaries
and their supporters (Gaupp 1919). These psychiatric diagnoses were
now addressed to a wider, non-professional audience. Such an interpretation of the disquieting political and social situation in terms of expert
scientific categories fell on a fertile ground, since it not only offered
explanations, but by its intrinsic logic also promised to identify causes and
potential treatments for the malady. In particular, the issue of the alleged
(financial) burden to the nation already addressed by Rudin in his article
ten years before became a major concern of Kraepelin, Rudin, and other
authors of the genre (for the importance of economic considerations in
Weimar psychiatry: Burleigh 1994; Siemen 1987).

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397

These issues and supposed solutions resonated with the major concerns of the public after 1918. The widespread anguish at the rise of mass
starvation and sickness, frequently associated with the loss of property and
social status, and with no clear prospect of improvement in the near future
broke down precepts of humanity and benevolence. The collapse of the
nation was perceived as a presage of the decline and ultimate annihilation
of the German Volk, and it provoked the conception of hitherto unthinkable extremes of radical thought, justified by the idea of national survival
(which one and a half decades later, under Nazism, would be followed
by translation into practice: Burleigh 1994; Proctor 1988; Roelcke et al.
1994).
In this situation, many people changed their minds about the value
of individual life, and Hoche was amongst them. His convictions and
perspective on the future had changed through his experience of the war
and the post-war turmoils. During the war he had written of the end of
atomistic individualism, and of the transformation of the nation into an
organism of a higher order. He argued that the Volk was such an organism
with rights above those of an individual (Hoche 1915). The nations defeat
alarmed him further, and the question of how to overcome the political and
economic crisis seemed to him to call for new solutions.
In 1920, Hoche and Karl Binding, formerly professor of law in Leipzig,
published a booklet Die Freigabe der Vernichtung lebensunwerten Lebens
(Legislation of the extermination of undeserving life). They described
the debilitated as a burden to the nation, as unproductive lives who in
addition had no self-awareness. Human ballast, these idiots were an
oppressive weight on the fit and healthy. In the given historical situation, it
was a national duty to eliminate this burden from the collective organism.
For this purpose, they advocated euthanasia, the mercy killing of the
mentally dead.
Thus, concern about the costs of modernity merged with that about the
costs of the war and its consequences. In this climate, professional interpretations which played on these sentiments and which promised ways
out of the supposed existential and, particularly, economic crisis were
eagerly received, whereas a more reserved attitude towards the interpretative potential of psychiatric categories received comparatively little attention: in 1922, Bumke published a second, completely revised edition of
his critique of the notion of degeneration. Here, he further developed his
multidimensional approach to the functional neuroses, and again rejected
the proposition that contemporary ailments and concerns were the result
of an ever-increasing threat due to a biological process of degeneration.

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But it was probably the cost argument which appealed to the wider
public in the political and economic crises 1918/1923 and again in 1929/
1932. At all events, Kraepelins and Rudins interpretation of the observable phenomena became the dominant reading of the facts during these
rather turbulent phases of pre-1933 Germany. Later, Rudin became the
main actor in the formulation of the 1934 law for enforced sterilisation of those allegedly suffering from hereditary conditions, which was
imposed immediately after the Nazi government came to power. He had
been lobbying for such a law for more than two decades. Starting in 1933,
he also headed the association of German psychiatrists, and he was at least
informed about the mass annihilation of the mentally ill, and about their
abuse as objects of psychiatric research (Roelcke et al. 1994; Weber 1993;
Weindling 1989).
In contrast, Bumkes individual-centered interpretation and its implied
call for social reform found its receptive audience in the mid-1920s, during
a short period of economic recovery and political stabilisation of the
Weimar republic. This does not imply that Bumke was not susceptible
to the temptations of nationalist politics (he indeed was: Schimmelpennig
1993), or that his approach was proof against misinterpretation or abuse.
But the historical development suggests that the Kraepelinian nosology and
the ensuing conceptualisations, more than competing approaches, carried
with them a particular intrinsic potential for political abuse (though not
as a necessary consequence). The crucial features of this potential may
have been the biologizing of social facts, the scientific inference from
these of an imminent threat to the collective culture or nation, which
coincided with public anxieties, and the equally scientific offer of means
of professional intervention in presumed abnormality.
CONCLUSION
The historical debate presented here concerns the relation between
psychopathological1 phenomena and social factors which were perceived
as characteristics of modern life. Whereas in the last decades of the 19th
century the debate was focused on the category of neurasthenia and its
supposed social origins, a decisive switch occurred after the turn of the
century when Kraepelin entered the stage. As a corollary of certain specific
presuppositions, his new nosology marginalised social factors which might
contribute to the etiology and symptom formation of psychiatric conditions.
Consequently, in this nosology, the category of neurasthenia was split
asunder. In regard to the debate on psychopathology and modernity,
Kraepelin shifted the focus of concern to the category of degeneration,

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399

which integrated somatic factors such as alcohol, syphilitic infection and

heredity and conceptualised them as the origins of social variables.
Although this position was thoroughly challenged by Hoche and, especially, Bumke, the political and economic conditions after the breakdown
of imperial Germany in 1918, and again after the world financial crisis of
1929, meant that in the end the interpretation of Kraepelin and his follower
Rudin prevailed.2
Looking back, it has to be stated that German medicine had (and still
has) considerable difficulties in coming to terms with its contributions to
Nazi society, including its atrocities, one of which was euthanasia for
the mentally ill. It may thus be important to understand the history of
psychiatry in this regard. While Kraepelin was not a Nazi (he died in 1926)
nor a practitioner of racialist hygiene, it would seem that he was the driving
force behind a program of scientizing psychiatry in a particular direction
which contributed in its own way to the abuse of psychiatry. For this reason,
Kraepelin needs to be seen more clearly in the context of his own times in
order for his full legacy to be more discriminatingly appreciated.
The historical developments illustrate how a set of apparently empirical facts (in this case clinical phenomena, epidemiological data, and
knowledge of laboratory research on the causation of syphilis) was at the
time open to widely different interpretations documented by the views of
Kraepelin and Rudin on the one hand, and Bumke on the other. These interpretations seemed in themselves to be coherent and convincing, as long as
certain pre-empirical suppositions were consciously or even unconsciously
accepted. It is not the purpose of this paper to evaluate the validity or even
the implications for efficacy of any of the presented approaches. Rather,
its aim is to point out the importance of the explicit or implicit presuppositions of apparently empirical, value-free research and its ensuing conceptualisations. Without doubt, from a historical point of view, Kraepelins
nosology and the theories derived from it were of great heuristic value to
many generations of psychiatrists. But they also diverted attention away
from certain issues, in particular social factors as independent variables in
psychological processes regarded as pathological, and they marginalised
or prevented the elaboration of these issues both in research and in practice.
I hope this paper may also draw attention to the importance of the
general political and, particularly, economic conditions that form the
backdrop to scientific research and conceptualisation in psychiatry. From
this perspective, the historical debate on some of the implications of
Kraepelinian nosology could be taken as a stimulus to reconsider the conditions under which Neo-Kraepelinian nosology evolved (Wilson 1993),

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and the context of its perpetuation in spite of the presence of alternative

approaches.
ACKNOWLEDGMENTS
This work was first outlined in a poster presented at the 2nd Research
Conference of the European Association of the History of Medicine and
Health, San Feliu (Spain), 27 September 1995. I am grateful to Professor
Arthur Kleinman, Harvard Medical School, for his suggestion to translate
my work into English for an American audience. I also thank Jonathan W.
Bolton, M.D., Pittsburgh, Thomas Schlich, M.D., Stuttgart, and Professor
Heinz Schott, Bonn, for critical comments on a draft version of this article.
NOTES
1. The terms psychopathology/psychopathological here refer to the historical actors
perspective.
2. This passage refers to the impact of Kraepelins and Rudins interpretations of modernity, neurasthenia, culture, and degeneration, and not to the history of the reception of
their general nosology (this would require a seperate study).

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Address for correspondence: Volker Roelcke, MD, M Phil., Medizinhistorisches Institut

der Universitat Bonn, Sigmund-Freud-Strae 25, D-53105 Bonn, Germany
Phone: +49 228 2875004; Fax: +49 228 2875007
E-mail: roelckev@mailer.meb.uni-bonn.de