Cadaver Brains and Excesses in Baccho and Venere: Dementia Paralytica in Dutch Psychiatry (1870-1920)

Abstract

This article explores the approach of dementia paralytica by psychiatrists in the Netherlands between 1870 and 1920 against
the background of international developments. The psychiatric interpretation of this mental and neurological disorder varied
depending on the institutional and social context in which it was examined, treated, and discussed by physicians. Psychiatric
diagnoses and understandings of this disease had in part a social–cultural basis and can be best explained against the backdrop
of the establishment of psychiatry as a medical specialty and the specific efforts of Dutch psychiatrists to expand their
professional domain. After addressing dementia paralytica as a disease and why it drew so much attention in the late nineteenth
and early twentieth century, this essay discusses how psychiatrists understood dementia paralytica in asylum practice in terms
of diagnosis, care, and treatment. Next we consider their pathological–anatomical study of the physical causes of the disease
and the public debate on its prevalence and causes.

Full text

Cadaver Brains and Excesses in Baccho and
Venere: Dementia Paralytica in Dutch
Psychiatry (1870 –1920)
JESSICA SLIJKHUIS*AND HARRY OOSTERHUIS**
*
Koraal Consulting, Heerlenerweg 10,6132 CM Sittard, The Netherlands. Email: jessica.
slijkhuis@mac.com
**
Faculty of Arts and Social Sciences, Maastricht University - History, PO 616 Maastricht,
6200 MD, The Netherlands. Email: harry.oosterhuis@maastrichtuniversity.nl
ABSTRACT.This article explores the approach of dementia paralytica by psy-
chiatrists in the Netherlands between 1870 and 1920 against the background
of international developments. The psychiatric interpretation of this mental
and neurological disorder varied depending on the institutional and social
context in which it was examined, treated, and discussed by physicians. Psy-
chiatric diagnoses and understandings of this disease had in part a social – cul-
tural basis and can be best explained against the backdrop of the establishment
of psychiatry as a medical specialty and the specific efforts of Dutch psychia-
trists to expand their professional domain. After addressing dementia paralytica
as a disease and why it drew so much attention in the late nineteenth and early
twentieth century, this essay discusses how psychiatrists understood dementia
paralytica in asylum practice in terms of diagnosis, care, and treatment. Next
we consider their pathological–anatomical study of the physical causes of
the disease and the public debate on its prevalence and causes. KEYWORDS:
psychiatry, neurology, professionalization, patient records, dementia paraly-
tica, paralysis, syphilis, brain anatomy, moral purity, The Netherlands.
THE clinical presentations associated with insanity in Dutch
asylums of the late nineteenth and early twentieth century dif-
fered substantially from those of patients in today’s psychiatric
hospitals. Compared to our current understanding of psychiatric
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disease, the concept of insanity prevalent around 1900 covered a
broader range of disorders. While today most patients suffer from
psychotic and mood disorders, a century ago such patients did not
exceed 60 percent of those admitted. The others suffered from fee-
blemindedness (20 percent), senile dementia (10 percent), and neu-
rological disorders, possibly in combination with mental disorders
(more than 8percent).
1
Nearly 40 percent of the insane were chronic
sufferers and not amenable to treatment. Asylums largely served as
nursing institutions; the share of patients annually dismissed as “recov-
ered” or “improved” was no more than one-third of the number of
insane annually admitted.
2
This article concentrates on one of these
chronic disorders, dementia paralytica. Specifically, we consider how
Dutch psychiatrists approached it in the years between 1870 and 1920
against the backdrop of the establishment of psychiatry as a medical
specialty and their effort to widen their professional domain.
In the period under study, however, the emerging field of psychia-
try was varied in shape and there were differences and even inconsis-
tencies between the clinical practices, scientific aspirations, and social
ambitions of psychiatrists. This becomes clear in particular in their
involvement with dementia paralytica. Relying on patient records
and medical publications as our main sources, our study reveals that
the psychiatric interpretation of this disorder would vary depending
on the institutional and social context in which physicians studied,
treated, or discussed it. Although one should not downplay the signifi-
cance of the physical and mental realities of dementia paralytica, it can
be argued that the interpretations put forward by doctors in their diag-
noses and explanations were framed in various institutional and social
contexts and, in part, had a social–cultural basis.
3
The first section of
the article provides basic information about the development of psy-
chiatry in the Netherlands in the second half of the nineteenth century
1. E. Borgesius and W. Brunenberg, Behoefte aan asiel? Woon- en zorgbehoeften van ‘achterblijvers’
in de psychiatrie (Utrecht: Trimbos-instituut, 1999), 15 –16;J.H.SchuurmansStekhoven,Ont-
wikkeling van het krankzinnigenwezen in Nederland 1813 –1914 (The Hague: Algemeene Lands-
drukkerij, 1922), Table VIII; H. Oosterhuis and M. Gijswijt-Hofstra, Verward van geest en ander
ongerief: Psychiatrie en geestelijke gezondheidszorg in Nederland (1870–2005),3vols. (Houten: Neder-
lands Tijdschrift voor Geneeskunde, Bohn Stafleu Van Loghum, 2008), 113 –15.
2. D. Schermers, “De toeneming van het aantal krankzinnigen in ons land,” Nederlandsch
Tijdschrift voor Geneeskunde,1913,57,589–601,594.
3. Compare to Charles Rosenberg and Janet Golden, eds., Framing Disease: Studies in Cul-
tural History (New Brunswick, N.J.: Rutgers University Press, 1992).
Slijkhuis and Oosterhuis : Dementia Paralytica 427
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and about dementia paralytica, a rare disease today. Next the paper dis-
cusses how doctors understood this illness: (1)inasylumpractice,as
geared to diagnosis, care, and treatment; (2)intheirlaboratoriesas
geared to pathological–anatomic research after the physical causes of
this disease; and (3) in debates on its prevalence and social– cultural
causes. The conclusion relates our findings about the Netherlands to
the British and American historiography about dementia paralytica.
THERISEOFPSYCHIATRYINTHENETHERLANDS
Even though institutional care of the insane has been around for cen-
turies, psychiatry as a medical field developed only in the nineteenth
century. In the Netherlands, the founding in 1871 of the Dutch Psy-
chiatric Association and the publication of the first psychiatric jour-
nal in 1876 by asylum doctors marked the beginning of psychiatry’s
formal development as medical specialty, which as of 1896 would be
combined with neurology. The Association’s leading members were
positivist, liberal-minded doctors who considered medical science a
crucial basis for social advancement. In their view, they were the ones
most qualified to be in charge of the care of the insane and this care
was supposed to have a medical basis.
Dutch asylum doctors, however, lagged behind their British,
French, German, and American colleagues, who had established pro-
fessional organizations and journals in the 1840sand1850s and who
had, at the same time, gained authority in the newly built asylums by
applying a new treatment called moral therapy, which relied on kind-
ness and a well-regulated pleasant environment to heal the damaged
mind.
4
As opposed to the surrounding countries, until the middle of
the 1880s hardly any new asylums were built in the Netherlands. The
trend-setting provincial asylum Meerenberg (1849) in the dunes near
4. Andrew Scull, “From Madness to Mental Illness: Medical Men as Moral Entrepre-
neurs,” Eur. J. Sociol.,1975,16,219 –61; Andrew Scull, “Mad-Doctors and Magistrates:
English Psychiatry’s Struggle for Professional Autonomy in the Nineteenth Century,”
Eur. J. Sociol.,1976,17,279 –305; Andrew Scull, Museums of Madness: The Social Organiza-
tion of Insanity in Nineteenth Century England (London: St. Martin’s Press, 1979), 183–85;
J. M. W. Binneveld, Filantropie, repressie en medische zorg. Geschiedenis van de inrichtingspsychia-
trie (Deventer: Van Loghum Slaterus, 1985), 32 –34; Jan E. Goldstein, Console and Classify:
The French Psychiatric Profession in the Nineteenth Century (Cambridge: Cambridge University
Press, 1987), 64–117; Eric J. Engstrom, Clinical Psychiatry in Imperial Germany: A History of
Psychiatric Practice (Ithaca, London: Cornell University Press, 2003), 16–50; Gerald N. Grob,
The Mad among Us: A History of the Care of America’s Mentally Ill (Cambridge, MA, and
London: Harvard University Press, 1994), 55–77.
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Haarlem was the exception that proved the rule. Most of the others
were older, renovated institutions in towns and until the 1870s physi-
cians usually played a minor role in the running of these mental
asylums. In their view, the patched up and overcrowded municipal asy-
lums did not meet the requirements for applying moral therapy and
neither did these institutions offer sufficient provisions for segregating
different groups of patients and for agricultural work and gardening,
which were considered curative for the insane. Municipal and religious
authorities, non-medical administrators, and charity institutions dis-
puted the authority and expertise of asylum doctors. The medical con-
trol over the admission of new patients was restricted by the first and
secondDutchinsanitylaw(1841 and 1884) which stipulated that hos-
pitalization in a mental asylum should be certified by a court of law.
5
In the 1880sand1890s, however, psychiatrists succeeded in establish-
ing more control over the operation of Dutch asylums. From the mid-
1880s onwards, the central government and provincial and local authori-
ties as well as voluntary and denominational organizations provided more
money for the care of the insane. A substantial number of new asylums
was built, all situated in the countryside and providing more room for
medical provisions such as separated wards for different groups of patients,
treatment facilities, and pathological– anatomical laboratories. By intro-
ducing a training program for psychiatric nurses, new treatments such
as bed care, prolonged baths, and occupational therapy as well as
restrictions on the use of mechanical restraints, asylum doctors came
nearer to realizing what they considered as proper medical care of the
insane. From around 1900, they also cleared the way for admitting
patients to asylums and psychiatric clinics without legal certification.
6
In the first half of the nineteenth century, reform-minded physi-
cians, philanthropists, and some civil servants were influenced by
French and British reforms in the care of the insane.
7
From the
5. Binneveld, Filantropie; Oosterhuis and Gijswijt-Hofstra, Verward van geest,43 –55;
H. Oosterhuis and J. Slijkhuis, Verziekte zenuwen en zeden: De opkomst van de psychiatrie in
Nederland (1870–1920)(Rotterdam: Erasmus Publishing), 37–56.
6. M. F. Gijswijt-Hofstra, ‘Within and Outside the Walls of the Asylum: Caring for the
Dutch Mentally Ill, 1884 –2000,’ in M. Gijswijt-Hofstra, H. Oosterhuis, J. Vijselaar, and
H. Freeman, eds., Psychiatric Cultures Compared: Psychiatry and Mental Health Care in the Twentieth
Century (Amsterdam: Amsterdam University Press), 35 –72; Oosterhuis and Gijswijt-Hofstra,
Verward van geest,70–185; Oosterhuis and Slijkhuis, Verziekte zenuwen en zeden,83–112.
7. See Joost Vijselaar and Timo Bolt, J. L.C . Schroeder van der Kolk en het ontstaan van de
psychiatrie in Nederland (Amsterdam: Boom, 2012).
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1860s onwards, however, German psychiatry, emphasizing a biomed-
ical approach, set the tone among prominent Dutch psychiatrists, the
more so in the 1890s when the first chairs and clinics for psychiatry
and neurology were set up at Dutch universities and psychiatric edu-
cation and scientific research were institutionalized at medical faculties.
They believed that psychiatry had to associate itself with modern med-
icine, neurology in particular, and that research in laboratories would
result in natural scientific explanations of insanity. Leading professors
and asylum doctors dissected and prepared the brains of their deceased
patients and gazed through their microscopes in search of the somatic
causes of mental diseases. However, the results of anatomical brain
research proved disappointing, and from the late 1890s on academically
employed psychiatrists, while dissociating themselves from the neuro-
logical reductionism of the biomedical approach, began to explore
other ways to establish their field as a clinical science. One of these
ways was the adoption of the clinical methods and disease classification
of the German psychiatrist Emil Kraepelin. He advocated systematic
observation of large numbers of patients, meticulous recording of clin-
ical pictures, statistical processing of mental symptoms, and experi-
mental psychological research in support of diagnostics.
8
Between 1870 and 1920, the number of Dutch physicians working
in the field of psychiatry and neurology increased more than tenfold
from around twenty to almost 220.
9
Well into the twentieth century,
the core activity of psychiatrists was to provide care to the mentally
ill in psychiatric institutions, but already by the end of the nineteenth
century they began to unfold professional activities outside asylums
as well. Apart from universities, they also worked in sanatoria and
clinics for nervous patients, in general hospitals, and in private prac-
tice. At the same time they sought to expand their professional domain
by advocating a larger role of psychiatry in the legal system and by
promoting hygienist measures in society aimed at preventing mental
and nervous disorders. Just like psychiatrists in some other European
countries, in particular in France and Germany, some of them
8. Oosterhuis and Gijswijt-Hofstra, Verward van geest,186–207; Oosterhuis and Slijkhuis,
Verziekte zenuwen en zeden,131 –57; see also H. de Waardt, Mending Minds: A Cultural His-
tory of Dutch Academic Psychiatry (Rotterdam: Erasmus Publishing, 2005).
9. Oosterhuis and Gijswijt-Hofstra, Verward van geest,64 –70; Oosterhuis and Slijkhuis,
Verziekte zenuwen en zeden,72 –75.
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presented themselves as experts in the field of mental hygiene in soci-
ety at large and as guardians of social order or popular educators.
10
DEMENTIA PARALYTICA:A DISTINCTIVE DISEASE OF THE
NINETEENTH CENTURY
Dementia paralytica expressed itself not only in physical symptoms,
such as paralyses, epileptic attacks, and motor, speech, and hearing
impediments, but also in various mental and behavioral disorders:
dementia, depression, mania, hallucinations, megalomania, and the
loss of memory, self-control, and self-consciousness.
11
Since the early
twentieth century, physicians have identified these symptoms as stem-
ming from neurosyphilis, the infection of the brain by the syphilis spi-
rochete. Dementia paralytica, first described as a disease by the French
physician Antoine Laurent Bayle in 1822, was also called general and
progressive paralysis (of the insane), paralysis cerebri and mentis,
insania paralytica, paralytic dementia and paresis, or, in popular par-
lance, “softening of the brain.”
12
By the twentieth century, the terms
parasyphilis and neurosyphilis were used as umbrella-terms for all the
mental and neurological disorders caused by syphilis.
13
Together with tabes dorsalis (syphilitic damage to the spinal cord
sometimes called “spinal consumption”) dementia paralytica marked
the last stage of syphilis, which could surface after five to twenty
years after infection among 5–10 percent of untreated syphilis suffer-
ers. Although physicians in the nineteenth century suspected a con-
nection with syphilis, there was no clear understanding of the
10. Oosterhuis and Gijswijt-Hofstra, Verward van geest,207–38; Oosterhuis and Slijkhuis,
Verziekte zenuwen en zeden,187 –239; R. Castel, L’ordre psychiatrique. L’a
ˆge d’or de l’alie
´nisme
(Parijs: Minuit, 1976); D. Blasius, Umgang mit Unheilbarem. Studien zur Sozialgeschichte der
Psychiatrie (Bonn: Psychiatrie Verlag, 1986); D. Blasius, ‘Einfache Seelensto
¨rung’. Geschichte der
deutschen Psychiatrie 1800 –1945 (Frankfurt am Main: Fischer, 1994); Robert A. Nye, Crime,
Madness, and Politics in Modern France. The Medical Concept of National Decline (Princeton,
N.J.: Princeton University Press, 1984); Goldstein, Console and Classify; Ian Dowbiggin,
Inheriting Madness. Professionalization and Psychiatric Knowledge in Nineteenth Century France
(Berkeley: University of California Press, 1991); Andrew Scull, “Psychiatry and Social Con-
trol in the Nineteenth and Twentieth Centuries,” Hist. Psychiatry,1991,2,149–69; Harry
Oosterhuis, Stepchildren of Nature. Krafft-Ebing, Psychiatry, and the Making of Sexual Identity
(Chicago, London: The University of Chicago Press, 2000), 85 –86,95 –96,100 –12.
11. H. van den Berg and B. Meijer, Zakwoordenboek van de psychiatrie (Amsterdam: Elsev-
ier, Arnhem: Koninklijke PBNA, 1994), 63.
12. E. M. Brown, “French Psychiatry’s Initial Reception of Bayle’s Discovery of General
Paresis of the Insane,” Bull. Hist. Med., 1994,68,235–53.
13. E. M. Brown, “Why Wagner-Jauregg Won the Nobel Prize for Discovering Malaria
Therapy for General Paresis of the Insane,” Hist. Psychiatry,2000,9,371 –82.
Slijkhuis and Oosterhuis : Dementia Paralytica 431
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relationship until the First World War. After the Germans Fritz
Schaudin and Paul Hoffmann had demonstrated that syphilis was
caused by a bacterial microorganism, the Treponema pallidum,in
1905, the German physician August von Wassermann developed a
test to reveal the presence of antibodies for syphilis in the blood. In
1913, with the discovery by Hideyo Noguchi and co-workers at the
Rockefeller Institute of New York of the syphilis microbe in the
brain of paralytics, it became clear that dementia paralytica consti-
tuted the tertiary stage of syphilis. Psychiatrists accordingly began to
employ the Wassermann test for diagnosing it.
14
While during the
1910s physicians began treating syphilis patients with salvarsan and
neosalvarsan, these drugs had little effect on the neurological damage
apparent in tertiary syphilis. Many patients died physically and men-
tally devastated, often within five years after the first symptoms. In
1917, the Austrian psychiatrist Julius Wagner-Jauregg discovered that
the disease’s progress could be halted through high fever induced by
artificial infection with malaria. This therapy, whereby the malaria in
turn was treated by quinine, was applied until the introduction of
penicillin in the mid-1940s as medication for syphilis and dementia
paralytica.
15
Paralysis received much attention in psychiatry of the late nineteenth
and early twentieth century. In medical–historical works we find three
explanations for this. First, from the 1880s, physicians observed a
strong rise of the number of paralytic cases. Some historians corrobo-
rate this medical perception, indicating that the prevalence of paralysis
had indeed increased because of a syphilis epidemic in Europe and
North America and the emergence and gradual spread of a virulent
neurotropic mutation of the syphilis microbe.
16
Second, dementia
paralytica seemed to be the exemplary disease that would substantiate
the medical ambition to find physical causes for mental disorders and
thus advance psychiatry as a full-fledged medical discipline. As some
14. Claude Que
´tel, History of Syphilis (Cambridge: Polity Press, 1990), 140–41,162 –63.
15.Que
´tel, History,325; Magda Whitrow, “Wagner-Jauregg and Fever Therapy,” Med.
Hist.,1990,34,294 –310; Joel Braslow, “The Influence of a Biological Therapy on Physicians’
Narratives and Interrogation: The Case of General Paralysis of the Insane and Malaria,” Bull.
Hist. Med., 1996,70,577 –608,582 –90; Edward Shorter, A History of Psychiatry: From the Era of
the Asylum to the Age of Prozac (New York etc.: John Wiley & Sons, 1997), 195;Brown,“Why
Wagner-Jauregg Won the Nobel Prize,” 378–80.
16. E. H. Hare, “The Origin and Spread of Dementia Paralytica,” J. Mental Sci.,1959,
105,594 –626: Shorter, A History of Psychiatry,53 –9.
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historians have stressed, psychiatrists were eager to give priority to
paralysis as a way to support their own scientific and professional aspi-
rations.
17
Third, dementia paralytica also played an important role in
the psychiatric discussion about the social and moral causes of mental
disorders and the preventive measures to be taken. In this context, the
special interest in this disease was linked up with the popularity of
degeneration theory and another professional ambition: the social –
hygienic expansion of the psychiatric domain.
18
DEMENTIA PARALYTICA IN THE ASYLUM
The sufferers of dementia paralytica ended up in asylums for the
insane or else these patients received nursing care at home or in spas,
sanatoria, and convalescent homes. The number of patients outside
of the asylums cannot be established. Quantitative data are available
about their numbers in asylums, but these statistics have to be handled
with caution. They are based on the psychiatric diagnostics of the day,
which may entail a distorted image of the actual prevalence of paralysis.
Before the introduction of the Wassermann test, there was no hard cri-
terion for diagnosing the disease and physicians depended on outward
symptoms. Some of the behavioral and neurological symptoms could
also be found in patients suffering from other diseases, such as alcohol-
ism, epilepsy, senile dementia, brain tumors, and other organic brain
diseases, multiple sclerosis, manic and depressive (bipolar) disorders, and
neurasthenia. Depending on the preoccupations of the physicians
involved, both over- and underreporting cannot be ruled out.
19
This lack of diagnostic clarity is reflected in the divergent numbers
of paralytics reported at the time, as well as in historical studies. The
17.Que
´tel, History,61;Engstrom,Clinical Psychiatry,107 –10;H.BinneveldandR.Wolf,
Een Huis Met Vele Woningen: 100 jaar katholieke psychiatrie Voorburg 1885 –1985 (Vught: Algemeen
Psychiatrisch Ziekenhuis Voorburg, 1985), 35; Braslow, “The Influence of a Biological Ther-
apy,” 580 –81.
18. George Rosen, Madness in Society: Chapters in the Historical Sociology of Mental Illness
(Chicago: The University of Chicago Press, 1968), 247 –58; G. Berr ios, “‘Depressive Pseu-
dodementia’ or ‘Melancholic Dementia’: A 19th Century View,” J. Neurology, Neurosurgery,
Psychiatry,1985,48,392 –400; G. Blok, Hersenverweking in Nederland: Het psychiatrisch vertoog
over dementia paralytica 1844–1930 (MA thesis, University of Amsterdam, 1995); 81 –83,89 –
90; G. Davis, “The Cruel Madness of Love”: Sex, Syphilis and Psychiatry in Scotland, 1880 –1930
(Amsterdam/New York: Rodopi, 2008), 199 –231.
19. Hare, “The Origin and Spread of Dementia Paralytica,” 612 –14; Rosen, Madness in
Society,247 –58; G. Berrios, “Depressive pseudodementia”; Blok, Hersenverweking,22–3;
Davis, “The Cruel Madness of Love,”104–16,141 –43,231.
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annual reports of the Dutch State Inspectorship for the Insane and
the Asylums show that between 1875 and 1915 their share in the total
asylum population in the Netherlands rose from over 2to nearly 7
percent and averaged 5.5percent.
20
These figures are lower than the
British, French, and American ones, which fluctuated between 6and
up to 20 percent and more.
21
Statistical data from some Dutch asylums
also point to higher percentages. The average share of paralytic patients
among the insane in the Coudewater asylum near ‘s-Hertogenbosch,
for example, was 2.5percent between 1870 and 1897, but it fluctuated
between 5and 15 percent between 1897 and 1914.
22
In the Willem
Arntsz Hospital in Utrecht their share was 1.4percent in 1875, rising
to almost 24 percent in 1900, and going down again to 11.8percent by
1915, while the average percentage was almost 11.
23
However, in their
historical studies based on patient records of four Dutch asylums (the
municipal asylums of Utrecht and Leiden, the Catholic asylum Voor-
burg near ‘s-Hertogenbosch, and the Protestant asylum Wolfheze near
Arnhem) Gemma Blok and Joost Vijselaar found that around 4.2per-
cent of the patients in their samples were suffering from dementia para-
lytica.
24
In our sample of patient records from the municipal asylum in
Deventer discussed in this article, 5.6percent pertain to paralytics.
Based on a sample of anonymized patient records of the
St. Elisabeth Hospital in Deventer (a medium-sized town in the east-
ern part of the Netherlands), it is possible to trace how asylum doc-
tors diagnosed and treated paralytic patients in clinical practice,
which causes they identified, and how their response can be under-
stood in the context of the problems they faced and their medical
ambitions. The St. Elisabeth Hospital was a town hospital, which
dated back to the sixteenth century and was formally recognized as a
medical asylum in 1841. Just like many other asylums in urban areas,
this mental institution struggled with a lack of space for separating
20. Blok, Hersenverweking,15; With respect to the year 1909, however, the statistics of the
Inspectorship, covering all Dutch asylums, indicated a much lower percentage: 2.4. Schuur-
mans Stekhoven, Ontwikkeling van het krankzinnigenwezen, Table VIII.
21. Hare, “The Origin and Spread of Dementia Paralytica,” 605,608 –9;Que
´tel, History,
161; Brown, “French Psychiatry’s Initial Reception,” 235; J. Braslow, “The Influence of a
Biological Therapy,” 581 –2,593; Davis, “The Cruel Madness of Love,”15,239.
22. J. W. M. Jongmans, Psychiatrisch ziekenhuis Coudewater 1870–1970. Medisch-historisch
verslag (Rosmalen: s.n., 1971), 70.
23. Blok, Hersenverweking,20–21.
24. Ibid.; J. Vijselaar, Het gesticht: Enkele reis of retour (Amsterdam: Boom, 2010), 50–51,
186.
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different categories of patients, as well as a lack of room for medical
facilities and insufficient space for gardens and fields where patients
could work and recreate. Therefore, a second asylum was built on
the premises of the Brinkgreven estate on the edge of town, which
opened its doors in 1894. Both asylums were municipal institutions.
With around 250 beds each in the first decade of the twentieth cen-
tury, they were among the country’s medium-sized asylums.
25
Although the records we studied are from paralytics hospitalized in
the St. Elisabeth Hospital, the Brinkgreven asylum is particularly
relevant for our analysis because it influenced and changed the
psychiatric approach of these patients.
Comparison of our findings with those of Gemma Blok, who con-
ducted similar research on paralytic patients of Utrecht’s municipal
asylum, the Willem Arntsz Hospital, between 1841 and 1914 reveals
somewhat higher prevalence in our sample. With over 400 beds at the
end of the nineteenth century, this asylum was considerably larger
than the two institutions in Deventer. Blok’s sample of 932 records
from a total of almost 11,000,resultedin39 records of paralytic
patients, a share of nearly 4.2percent. Only one of these records dates
from before 1884.
26
In our sample of 353 patient records from the period 1870 –1914,
randomly selected from the more than 1,400 records still available of
patients admitted to the St. Elisabeth Hospital and the Brinkgreven
asylum, twenty pertain to sufferers of dementia paralytica. All twenty
were hospitalized in the St. Elisabeth Hospital.
27
This amounts to a
share of slightly over 5.6percent of the total number of patients in
the sample. One of the paralytic patients was admitted in 1870, three
of them between 1884 and 1889, two of them between 1894 and
1897, seven of them between 1903 and 1906, and also seven of them
between 1910 and 1914. With one exception, all these paralytic
25. Oosterhuis and Gijswijt-Hofstra, Verward van geest,1401,1403; cf. C. M. Hogenstijn,
Sint Elisabethsgasthuis en Brinkgreven: Geschiedenis van de psychiatrische ziekenhuizen te Deventer
(Deventer: Arko boeken, 1987); J. Vijselaar, ed., Over de IJssel, over de schreef: De geschiedenis
van de geestelijke gezondheidszorg in Overijssel en van het Psychiatrisch Ziekenhuis Brinkgreven in
het bijzonder (Utrecht: Nederlands centrum Geestelijke volksgezondheid, 1993).
26. Blok, Hersenverweking,6,20–22.
27. The records are stored in the archive of the regional organization for mental health
care, the Archief Adhesie GGZ Midden Overijssel. We established our sample by selecting
every fourth record from the box files in which the records are arranged in alphabetical
order on the basis of the patients’ names. In our references, we indicate the archival number
of the record and the years in which the patient involved was hospitalized.
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patients died in the hospital, fifteen of them within two years and
four within five years.
28
They had worked as merchant, baker, black-
smith, laborer, factory worker, military man, civil servant or book-
keeper, or they were retired. In some cases, their profession was not
listed. Nineteen patients were married, and one man was a widower.
Among the twenty paralytics, there was only one woman.
29
Although
the share of female paralytic patients in the Willem Arntsz Hospital
(18 percent) and in all Dutch asylums (14 percent) was larger, our
Deventer sample does reflect the general picture that most paralytic
patients (some 75 percent) were men between ages thirty and sixty.
30
In order to compare the diagnosis and treatment of dementia paraly-
tica with other clinical pictures, we have also selected and studied ten
records of other patients hospitalized in the St. Elisabeth Hospital and
the Brinkgreven asylum. These records are about patients suffering
from, as the asylum doctors noted down, “hallucinations and delu-
sions,” “depressed temper,” “melancholy,” “vecordia hallucinations,”
“secundairy dementia,” “dementia praecox,” “moral insanity,” “neur-
asthenia,” and “dementia epileptic.” In one of these ten records, no
diagnosis is mentioned.
31
Regardless of the length of patients’ hospitalization, records tend
to be no longer than three pages. This limited size and their selective
content are related to their function at the time: the reporting pri-
marily served to support the legally required medical certificate of
insanity and the court authority required for asylum admission. The
Dutch insanity law of 1884 stipulated physicians to record their find-
ings on patients every day during the first two weeks after their admis-
sion. These notes were to be used in a medical report sent to the
judge in order to request either prolonged admission or the patient’s
discharge. After this first period, doctors needed to update reports on
a weekly basis in the following six months and on a monthly basis
28. In the Willem Arntsz Hospital, the average admission of paralytics lasted ten months.
Blok, Hersenverweking, 1995,18. The statistics of the State Inspectorship indicate that 25
percent of all the paralytics hospitalized in Dutch asylums died within three months and
almost 60 percent within a year after admission. D. Schermers, “Eenige statistische beschou-
wingen over de psychosen in Nederlandse krankzinnigengestichten gedurende de jaren
1875 –1900,” Psychiatrische en Neurologische Bladen,1906,10,47 –50,47 –49.
29. For an overview of the personal and diagnostic information on paralytic patients in
the St. Elisabeth Hospital, see Tables 1and 2.
30. Ibid., 47: Blok, Hersenverweking,15–16,20 –21.
31. For an overview of the personal and diagnostic information on these patients, see
Tables 3and 4.
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TABLE 1
Personal and diagnostic information on paralytic patients in the St. Elisabeth Hospital, 1870 –1914 (from Patie
¨ntendossiers
van het St. Elisabethsgasthuis en Brinkgreven, Archief Adhesie GGZ Midden Overijssel)
Record
number
Year of
admission
Age at the time
of admission
Sex Year of discharge
or death
Civil status Length of
hospitalization
in years
Profession
1302 1870 46 Male 1872 Married 2Retired
2052 1884 48 Male 1884 Married ,1Retired soldier
402 1886 57 Female 1888 Married 2Housewife
486 1889 48 Male 1889 Unknown ,1Not recorded
692 1894 44 Male 1896 Divorced 2Not recorded
1031 1897 42 Male 1900 Married 3Workman
1437 1903 52 Male 1903 Married ,1Baker
1521 1903 42 Male 1904 Married 1Bookkeeper
1622 1904 34 Male 1909 Married 5Workman
1657 1905 45 Male 1907 Married 2Workman
1680 1905 45 Male 1908 Married 3Mechanic
1709 1905 42 Male 1906 Married 1Merchant
1809 1906 43 Male 1907 Married 1No profession
2082 1910 58 Male 1910 Married ,1Butcher-hand
2249 1912 38 Male 1915 Married 3Workman
2299 1913 48 Male 1913 Married ,1No profession
2379 1913 46 Male 1913 Widower ,1Innkeeper
2422 1913 56 Male 1915 Married 2Blacksmith
2482 1914 34 Male 1914 Married ,1Not recorded
2499 1914 39 Male 1914 Married ,1Manufacturer
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TABLE 2
Personal and diagnostic information on paralytic patients in the
St. Elisabeth Hospital, 1870 –1914 (from Patie
¨ntendossiers van het
St. Elisabethsgasthuis en Brinkgreven, Archief Adhesie GGZ Midden
Overijssel)
Record
number
Religion Diagnosis Recorded cause of suffering
1302 Protestant General paralysis Not recorded
2052 Protestant Dementia paralytica Quarrel with his boss
402 Nonconformist Dementia paralytica Hypochondria; sorrow
because of children
leaving home
486 Unknown Paralysis Not recorded
692 Catholic General paralysis Unable to separate from
his wife
1031 Protestant Dementia paralytica Unrecorded. Patient
denies suffering from
lues
1437 Protestant Dementia paralytica Alcoholism and lues
1521 Protestant Dementia paralytica No evidence of having
suffered from lues, of
alcoholism; has lived a
very calm life
1622 Protestant Paralysis Not recorded
1657 Protestant Dementia paralytica Alcoholism
1680 Lutheran Dementia paralytica Unknown
1709 Protestant Dementia paralytica Tramping; problem
drinking
1809 Protestant Dementia paralytica Conflicts with his boss
2082 Protestant Dementia paralytica Lues, problem drinking
2249 Catholic Dementia paralytica
Paranoia
Adultery
2299 Protestant Dementia paralytica Probably lues
2379 Protestant Dementia paralytica Very hectic life; patient
denies suffering from
lues
2422 Catholic Taboparalysis Not recorded (his wife
suffers from “lues
cerebro spinalis”)
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during the remaining period of hospitalization. The reporting was
mostly brief and mainly served to legitimate the patients’ diagnosis of
insanity and their (prolonged) admission. Admissions were frequently
motivated by social concerns rather than by strictly medical ones.
The extensive attention for agitated, troublesome, and dangerous
conduct underscored the social function of asylum psychiatry: as a
diagnosis, dementia paralytica justified court-sanctioned hospitaliza-
tion to protect the individual patient against himself as well as to
ensure the safety of his next of kin and of society.
32
One record from
1884, for example, said that the megalomania and hallucinations of
one patient made him “completely unsuitable” for engaging in social
interaction on his own: his prolonged hospitalization was considered
necessary to ensure “public order.”
33
A forty-six-year-old man with
“general paralysis,” who suffered from “symptoms of megalomania and
...attacks of restlessness,” was admitted because it “is dangerous to
leave him on his own.”
34
Another patient was “intolerable” at home
and “dangerous to his environment; he wanted to abuse his child and
put himself, or his head, into the oven.”
35
The records underscore the helplessness of paralytic sufferers: many
could hardly speak, walk and sit, let alone work—activities which
posed no major challenge to many other mental patients. Some of
them were so hard to restrain that doctors had to take recourse to
coercive means. A thirty-five-year-old factory worker who in 1904
thought that single-handedly he had to end the war between Russia
and Japan, could “be brought under control only with great difficulty,
2482 Not recorded Dementia paralytica Syphilis: Wasserman test
positive
2499 No religion Dementia paralytica Syphilis: Wasserman test
positive
32. Vijselaar, Het gesticht,16–18,83 –122.
33. Patient record 2052 (1884).
34. Patient record 1302 (1870–72).
35. Patient record 486 (1889).
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TA B L E 3
Personal and diagnostic information on other patients in the St. Elisabeth Hospital and the Brinkgreven Asylum,
1870 –1914 (from Patie
¨ntendossiers van het St. Elisabethsgasthuis en Brinkgreven, Archief Adhesie GGZ Midden
Overijssel)
Record
number
Year of
admission
Age at the time
of admission
Sex Year of discharge
or death
Civil status Length of
hospitalization in years
Profession
1719 1879 60 Male 1879 Married 0(died) Workman
1839 1881 52 Male 1881 Married 0(recovered) Baker
1962 1883 45 Male 1903 Not recorded 20 (died) Not recorded
2042 1884 23 Male 1902 Not recorded 8(transferred) Workman
969 1897 53 Female 1901 Married 4(not recovered) No profession
1149 1899 33 Male 1905 Married 6(died) Butcher
1682 1905 20 Male 1905 Married 0(recovered) Shop-assistant
2137 1910 30 Female 1911 Not recorded 0(not recovered) Not recorded
2170 1911 Not recorded Male 1911 Not recorded 0(recovered) Not recorded
2389 1913 23 Male 1918 Widower 5(died) Not recorded
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and this repeatedly calls for the use of wet packs and hyoscine.”
36
Because of their delusions, interaction with paralytics was frequently
hard if not impossible. Still, several records also contained detailed
descriptions of their moods and actions. In 1870, one doctor wrote
about a patient:
He is satisfied here in the asylum ...; all day he is leafing through a
book, without reading in it. His conversations are highly childish, his
speech is stammering; he staggers; his feeling has dulled, and his cons-
tant dirtiness suggests that he fails to notice his natural urges. He eats
with vigour, but in this too he shows no sense of taste because he
mixes all he’s eating. His condition never shows any change ...When
in need of help, he can be angry and short-tempered.
37
References to infirmity, apathy, agitation, and aggression occurred
frequently in the records from the 1870sand1880s. One record notes
TABLE 4
Personal and diagnostic information on other patients in the St. Elisabeth
Hospital and the Brinkgreven Asylum, 1870 –1914 (from Patie
¨ntendossiers
van het St. Elisabethsgasthuis en Brinkgreven, Archief Adhesie GGZ
Midden Overijssel)
Record
number
Religion Diagnosis Recorded cause of
suffering
1719 Not recorded Not recorded Operations of the eye
1839 Protestant Hallucinations; delusions Offended sense of
honor
1962 Not recorded Depressed temper Not recorded
2042 Not recorded Melancholy Not recorded
969 Protestant Vecordia hallucinations Not recorded
1149 Protestant Secundairy dementia Not recorded
1682 Not recorded Dementia praecox Problem drinking;
epileptic fits
2137 Not recorded Moral insanity Unknown
2170 Not recorded Neurasthenia Tainted stock
2389 Not recorded Dementia epileptica Not recorded
36. Patient record 1622 (1904–09).
37. Patient record 1302 (1870–72).
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the following about a paralytic characterized as very disturbed and dan-
gerous: “At night he was restless; left his bed to walk out and when
stopped, he started cursing heavily.”
38
In the record of a fifty-seven-
year-old woman one reads:
The sufferer is dazed and does not respond to any questions; ...does
not eat on her own and is expressionless. At night she was unclean;
just sits there staring thoughtlessly and is fully in need of help. She
lacks any sense of what goes on around her.
39
Furthermore, the quite detailed representation in the records of the
content of delusions, hallucinations, and megalomania is striking.
For example, about a retired military man in an advanced stage of
dementia paralytica, the doctor wrote:
He thinks I am the king, regularly calling me “Sire”; believes that
through his bravery and heroism he can benefit me greatly; he has
plans for various expeditions in the Dutch Indies that he can success-
fully complete in the wink of an eye, as he, being a Field Marshal
with twelve years of experience, did already. ...Hallucinations, at
night he hears his wife, and maidens are brought to his bed. As if
being a great hunter, he wants to present to me as a gift his catch:
lions, tigers and other wild animals captured alive. He recounts all
sorts of stories about his experiences; there is nothing he cannot do,
no one has so many achievements as he.
40
Also in some of the records of patients suffering from other mental
disorders, the physicians made much of the content of their delu-
sions. “He believes to be in his own castle, which he wants to recon-
struct in the most extravagant way,” one of the asylum doctors wrote
about a man whose diagnosis is not recorded.
41
And a baker who was
hallucinating “tells various stories, how he has eaten letters ...how he
wants to improve the conditions in prisons and asylums, how he wants
to reform the licensing act.”
42
These records also show, however, that
there was more communication between the physicians and these
patients and that the physicians took more interest in their experi-
ences. For example, in the record of a man suffering from “depressed
38. Patient record 486 (1889).
39. Patient record 402 (1886 –88).
40. Patient record 2052 (1884).
41. Patient record 1719 (1879).
42. Patient record 1839 (1881).
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temper,” the doctor expressed empathy for his worries about his fam-
ily: “he fears that his wife and children are not doing well, he is
excited and shows remorse in a childish way.”
43
In the record of a
workman who was diagnosed with “melancholy,” the physician wrote
that “he lowered his eyes ...and was afraid. When I asked him about
his worries he says that his depression has slightly diminished, but that
he does not believe that he will recover; only with difficulty and hesi-
tantly he talks about himself.”
44
Similar information can be found in
the record of a neurasthenic patient. Although this record also
included entries about body temperature, respiration, body weight,
blood pressure, and mental functions, the physician did not act as a
detached observer. His notes showed that he talked to this patient and
asked him to tell him his life story, of which fragments were recorded;
he was particularly interested in how the patient’s fears and worries
had come into being and how these were related to his descent and
particular dramatic events in his life.
45
Inasmuch as the doctors recorded their views on the causes of
paralysis, they looked for them mainly in relational and emotional
factors, such as conflicts and sorrow, as well as in bad habits and an
irregular way of life. The record about the female patient referred to
above stated that her illness was caused by sorrow because her chil-
dren had left her.
46
In the record of a forty-four-year-old man, one
can read that “the main cause was that he was unable to separate
from his wife.”
47
And, as the doctor reported, two patients came
down with paralysis after conflicts with their boss.
48
Other causes of
dementia paralytica mentioned in the records are syphilis, hypo-
chondria, alcoholism, tramping, adultery, and a hectic life.
49
In the
records of paralytics as well as of the other patients there are hardly
any explicit references to somatic or hereditary causes, and little is
registered about therapeutic treatment.
50
Often, the paralytics who
43. Patient record 1962 (1883–1903).
44. Patient record 2042 (1884–1902).
45. Patient record 2170 (1911).
46. Patient record 402 (1886 –88).
47. Patient record 692 (1894 –96).
48. Patient record 2052 (1884); 1809 (1906 –07).
49. Patient records 402 (1886 –88); 1437 (1903); 1657 (1905–07); 1709 (1905 –06); 2082
(1910); 2249 (1912 –15); 2379 (1913); 2482 (1914); 2499 (1914).
50. In the records of the Willem Arntsz Hospital Blok found brief notes about treatments
of paralytic patients with medication (bromide, morphine and, from 1914 on, neo-salvarsan),
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ended up in the asylum were so ill already that their condition hardly
changed, let alone improved. Notes such as “any change for the
better is no longer to be expected at this stage”
51
and constantly reit-
erated expressions such as “condition unchanged,” “the same condi-
tion,” “idem,” and “as before” indicate that there was little physicians
could do for these patients.
In 1894, the new Brinkgreven asylum opened its doors. It was led
by chief medical officer Willem H. Cox, who in 1899 was succeeded
by Jean L.C.G.A. le Ru
¨tte. These innovation-minded asylum doc-
tors felt that care for the insane should be organized in the same way
as somatic medicine. They hired medically trained nursing staff and
separated quiet and restless patients from each other. In contrast to
the St. Elisabeth Hospital, Brinkgreven had several medical facilities,
such as an operating room, a pharmacy, and a laboratory for patho-
logical–anatomic research. Apart from restful bed care, doctors pre-
scribed hydrotherapy and medication, and they applied moral treatment
based on outdoor work and relaxation activities. They tried to banish
coercive measures as much as possible, but could not refrain from them
altogether. Agitated and unmanageable patients were administered large
doses of sleeping drugs and sedatives or, in the context of continuous
hydrotherapy, they were wrapped in wet packs.
52
Whereas mental
patients considered treatable were admitted to the new asylum, those
viewed as incurable, among them all paralytics, stayed behind in the old
St. Elisabeth Hospital.
Although the medical–somatic approach in the Brinkgreven asy-
lum did not alter the way the asylum doctors explained the causes of
paralysis and did not result in effective therapies for it, the records
show that in the St. Elisabeth Hospital this approach did bring about
changes in the way the symptoms of this disease were recorded. The
reporting on actual abnormal behaviors and mental symptoms such
as delusions and hallucinations became more succinct; these aspects
were merely observed and concisely noted down. From 1894 doctors
paid more attention to the physical condition of patients and
continuing hydrotherapy, restraints, isolation, and “talk in order to calm down,” Blok, Hersen-
verweking,29–31.
51. Patient record 1680 (1905–08).
52. Hogenstijn, Sint Elisabethsgasthuis en Brinkgreven,70–77; Vijselaar, Over de IJssel,
10 –11,27.
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proceeded more systematically. They recorded their pulse, body tem-
perature, breathing and weight, described abnormalities of their motor
system, and checked systematically whether patients ate and slept well.
Increasingly doctors geared their attention to somatic, especially neu-
rological symptoms, which they indicated in standardized jargon. For
example, in a record from 1894, one can read that the patient had “a
light attack of apoplexy [seizure]” which “impeded his speech move-
ments.”
53
About a forty-two-year-old worker, one record says:
He has a sturdy build, displays anisocoria [unequal size of the pupils],
left pupil smallest, paralytic speech disorders, left-sided facial nerve
paralysis, innervations disorders, tremors ..., heightened knee
reflexes, does not know what time or day it is, nor his year of admis-
sion; cannot calculate his age. Dementia paralytica.
54
Further, the somatic approach was expressed in questions posed by
doctors on the incidence of mental and nervous disorders in the
family, an element that suggests increased attention for heredity and
degeneration, although these factors are not explicitly mentioned as
cause of dementia paralytica.
55
Blok observed a similar development in the records of paralytic
patients in the Willem Arntsz Hospital from 1890 onwards. The volume
of records increased after the physicians began to register more informa-
tion about the life history of patients and their physical examination.
Similarly, the records gradually contain more notes about the informa-
tion that the doctors collected from the patients’ relatives and other phy-
sicians, in particular with regard to the possible hereditary background
of dementia paralytica.
56
The records of the St. Elisabeth Hospital from after the mid-1890s
indicate that more than in the few earlier records the diagnosis of
paralysis had turned into a medical routine. This is exemplified by a
record from 1903 of a patient who was lying in bed mostly dull and
who occasionally was noisy: “Speech disturbances, defective mem-
ory, pareses [muscular paralysis] of his facial muscles, abnormal
pupils, dirtiness, susceptibility to bedsores—all part of the normal
53. Patient record 692 (1894 –96).
54. Patient record 1031 (1897–1900).
55. Patient records 2299 (1914), 2482 (1914), 1521 (1903 –4), 1809 (1906 –7), 2137
(1910 –11), 2299 (1913), 2422 (1913 –15) and 2170 (1911).
56. Blok, Hersenverweking,26–28.
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picture of progressive paralysis.”
57
Other records contain notes such
as “typical paralytic speech”; “patient speaks very awkwardly, has
strong ataxia [uncertain gait when walking], tremors, dementia, used
to have lues. Dementia paralytica nearly follows automatically as diag-
nosis”; and “suffering from dementia paralytica with all its classic
symptoms.”
58
Likewise, remarks on the prognosis of the disease under-
score the increased routine-like approach: “in this advanced stage one
is to expect merely further deterioration”; “where all somatic and
mental symptoms of dementia paralytica are present, the likelihood of
permanent asylum care is very high”; “prognosis highly unfavourable
of course; probable duration estimated not to be long.”
59
The efforts toward more objective observation, more routine-like
classification, and emphasis on physical examination suggest a larger
familiarity with paralysis. It is not evident, however, that these aspects
are also indicative of the professional endeavor of asylum doctors to
provide their field with a stronger medical image. The comparison
of the records of paralytic patients and those of other mental sufferers
from the years between 1895 and 1914 shows that the focus on phys-
ical and neurological symptoms was only typical of the psychiatric
reporting on dementia paralytica. The asylum doctors also per-
formed physical examinations of other patients, but at the same time
they continued to follow an individualized approach and to elaborate
on their behavior and experiences. In the record of a workman
whose “insanity showed itself in a depressed temper,” for example,
somatic symptoms were mentioned (“trembling of the facial muscles,
enlarged pupils”), but one can also read about his character and frame
of mind. He accused himself of “wrong acts ...he was afraid and felt
gloomy because he was so sinful in everything.”
60
From around 1895, the asylum doctors followed a neurological
approach in their diagnosis of dementia paralytica and their registra-
tion of its symptoms, but in their causal explanations this was not the
case. At the same time, they also looked to the clinical approach of
the German psychiatrist Emil Kraepelin. His method started from
detailed and standardized registering of observable symptoms with
57. Patient record 1437 (1903).
58. Patient records 2299 (1913), 1657 (1905–7) and 1437 (1903).
59. Patient records 1437 (1903), 1680 (1905–8) and 1809 (1906 –7).
60. Patient record 2042 (1884–1902).
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an eye to the statistical basis of diagnosis and prognosis. The patient
records suggest that the influence of Kraepelin’s disease classification
became tangible as of the late 1890s. Prior to that time, diagnosis
was mostly based on observation pertaining to the most striking
symptom, disturbing conduct, or suspected cause of mental disease.
Such approach, according to Kraepelin, was random and speculative;
to him, symptoms were only relevant for the diagnosis if these were
related to the course of a disorder.
61
Changes in the questions posed
by the doctors upon patients’ admission suggest that the doctors in the
St. Elisabeth Hospital applied Kraepelin’s classification. Questions about
a patient’s “social status,” “temperament,” and “civilization” receded to
the background, as was true of queries on the trigger or occasion of
insanity, while questions about the emergence, course, and duration of
the disorder gained more prominence. Doctors also considered harmful
influences before or during birth, alcohol use, sexual contact, as well as
the presence of nervous and mental disease and tuberculosis, syphilis,
and alcoholism in the family.
For the treatment of dementia paralytica little changed for the time
being, that is, until the arrival of malaria fever therapy around 1920.
The sole advantage of Kraepelin’s method was that it offered certainty
about the disease’s fatal outcome. Also, from the late 1890s onwards,
physicians referred more often to lues (syphilis). In our sample of
patient records, “lues” first appears in an anamnesis from 1897, while
later records on paralytics mention it as possible causal factor, often in
combination with alcohol abuse, “marital infidelity,” and “sexual
excesses.”
62
In a record from 1903, for example, the doctor noted that
in the past the patient was treated because of a “luetic infection” and
tended to “excesses in Venere and Baccho.”
63
In two records from
1914, there is the simple brief note saying that the “Wassermann was
highly positive.”
64
A formulation like “probable causes” suggests that
the doctors assumed a causal relation between syphilis and dementia
paralytica, but that they attached as much value to alcoholism and
61. On Kraepelin see Shorter, History of Psychiatry,100 –109; on Kraepelin’s influence on
Dutch psychiatry: Oosterhuis and Gijswijt-Hofstra, Verward van geest,199–200.
62. Patient records 1031 (1897 –1900), 1521 (1903 –4), 1622 (1904 –9), 1680 (1905 –7),
2249 (1912 –15) and 2422 (1913 –15).
63. Patient record 1437 (1903).
64. Patient records 2482 (1914) and 2499 (1914).
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sexual debauchery as well as sorrow, conflicts, and particular ways of
life (“tramping” and “a hectic life”) as causal factors.
65
The records the Willem Arntsz Hospital studied by Blok show a
similar trend. Syphilis as a cause for paralysis appeared for the first
time in 1895. In the period thereafter, the physicians referred in sev-
enteen of the thirty-nine records to syphilis as a causal factor, often
together with other causes, such as alcoholism, financial worries, and
“trauma capitis.” In five records dating from after 1895, physicians
reported that the patients had not contracted syphilis. Strikingly, four
records mention positive results of the Wassermann-test, whereas at
the same time the cause of dementia paralytica was referred to as
“unknown.” In eleven records, there are no notes at all about causes.
According to Blok, the more frequent references to syphilis should not
lead to the conclusion that the doctors in Utrecht believed in a strong
causal link between syphilis and dementia paralytica, as they would
also ask patients suffering from other mental disorders about their pos-
sible contraction of syphilis. Apparently this question had become part
of the medical procedure of all admissions.
66
DEMENTIA PARALYTICA IN THE PATHOLOGICAL –ANATOMIC
LABORATORY
The standardization of the diagnostic terminology, the attention for
somatic symptoms, and the effect of Kraepelin’s approach in our
sample of records from the mid-1890s onwards reflect the objective
of psychiatrists to emphasize the medical nature of their field. How-
ever, this hardly made an end to their therapeutic powerlessness.
From the angle of curative medicine, the treatment of paralysis was
all but an example of triumphant medical psychiatry. In the journal
of the Dutch Psychiatric and Neurological Association, the psychia-
trist F. Meeus labeled these patients as hopeless “mental cripples”:
“They reside in the eternal darkness of the mental night, where, like
Dante, one could write on the gates of hell: Who enters here abandons
all hope.”
67
On the other hand, the psychiatric discussions on the
65. Patient records 402 (1886–88); 1437 (1903); 692 (1894 –96); 1521 (1903 –4); 1657
(1905 –7); 1709 (1905 –6); 1809 (1906 –7); 2082 (1910); 2249 (1912 –15); 2379 (1913).
66. Blok, Hersenverweking,72–77.
67. F. Meeus, “Over ‘Dementia’ en hare waarde in de hedendaagsche Psychiatrie,”
‘Psychiatrische en Neurologische Bladen,1908,12,413 –29,415.
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disease’s physical basis revealed that psychiatrists capitalized on paral-
ysis to underline their medical–scientific aspirations.
The therapeutic pessimism in the asylums contrasted with the
optimistic tone with which they reported on their scientific research
of dementia paralytica in publications. Between 1886 and 1914,
some fourteen reports on pathological–anatomic research of paraly-
sis appeared in Dutch. In addition, psychiatrists published many case
histories of patients. Contributions about this disease in their profes-
sional journal outnumbered those on any other disorder. It seems that
this growing medical attention ran parallel to the increasingly stronger
focus of Dutch psychiatry on neurology. Studies were performed in
particular in laboratories of new asylums and clinics that were linked
to universities. The authors of the research reports, including the
university-professors Cornelis Winkler, Gerbrandus Jelgersma, and
Leendert Bouman, and one of the leading asylum doctors, Jacob van
Deventer, advocated a science-based psychiatry. They took advantage
of this disorder to prove that there was a connection between mental
diseases and brain and nervous disorders. They also used dementia
paralytica as an example to demonstrate that the insane were “nor-
mal” ill people and that it was productive to organize the care for the
insane after the model of the general hospital.
68
Many pathological– anatomic contributions about paralysis came
from physicians who worked at Endegeest, the asylum which had
laboratories and examination rooms and which was set up in part
for psychiatric training by Jelgersma at Leiden University.
69
68. See C. Winkler, “De psychopathologie als hersenpathologie te midden der klinische
wetenschappen,” supplement of Psychiatrische Bladen,1885,3,1–24; C. Winkler and
P. Wellenbergh, “Bijdrage tot de casuı
¨stiek der dementia paralytica,” Psychiatrische Bladen,
1886,4,34 –59; G. Jelgersma, “Idiotie en dementia paralytica. Pathologisch-anatomische
bijdrage,” Psychiatrische Bladen,1886,4,92 –122; G. Jelgersma, Psychologie en pathologische
psychologie: Rede bij de aanvaarding van het hoogleeraarsambt aan de Rijksuniversiteit Leiden, op 20
september 1899 uitgesproken door Dr. G. Jelgersma (Leiden: S. C. Van Doesburgh, 1899); J. van
Deventer and A. M. Benders, “Twee gevallen van dementia paralytica, na de inwerking van
een trauma capitis op den leeftijd respectievelijk van 9en 11 jaar opgetreden,” Psychiatrische
en Neurologische Bladen,1898,2,118 –21; J. van Deventer and F. Muller, “Een geval van
paralyse met innervatorische apraxie en apractische aphagie,”Psychiatrische en Neurologische
Bladen,1911,15,164 –84.
69. J. P. Hulst, “Een geval van infantiele progressieve paralyse,” Psychiatrische en Neuro-
logische Bladen,1900,4,101 –13; J. P. Hulst, “Een geval van dementia paralytica als paranoia
hallucinatoria debuteerend,” Psychiatrische en Neurologische Bladen,1902,6,25 –34; J. van der
Kolk, “De differentiaaldiagnose der Dementia paralytica met de zgn. alcoholische Pseudo-
paralyse,” Psychiatrische en Neurologische Bladen,1906,10,189 –205;J. van der Kolk, “Een
geval van tumor cerebri, gedurende het leven gehouden voor een snel verloopenden vorm
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Pathological –anatomic research was also performed at other institu-
tions, such as the new Bloemendaal asylum near The Hague. As its
chief medical officer A. Deenik wrote: “at Bloemendaal it is common
practice, introduced by Prof. Bouman [the former chief medical offi-
cer] and systematically continued by me, to cut samples from the
brain—both left and right hemisphere—of each cadaver available for
dissection.”
70
The significance of neurological and pathological–anatomic study
of dementia paralytica was underlined in the psychiatric textbooks
geared to academic education and the training of nurses. For exam-
ple, J.W.H. Wijsman, in his Lectures on Psychiatry for Students, Physi-
cians and Lawyers (1896), extensively addressed the neurological
aspects of the disorder: “In recent years our knowledge of the patho-
logical anatomy of dementia paralytica has significantly increased
through careful investigations owing to the advances in microscopic
technology.” In detail, he described the abnormalities in the brain
tissue that would be characteristic of paralysis, such as ganglion cells
[neurons] that showed “fatty degeneration, atrophy [decrease in size
or wasting away of part of the body] and sclerosis [pathological hard-
ening of tissue]”; damaged nerve fibers in the cerebral cortex and in
the great and the little brain; “atheromatosis” [fatty degeneration of
the interior walls] of the large blood vessels and “increase of nuclei
and colloid [viscous] and hyaline [vitreous] degeneration” of the vas-
cular wall of the small blood vessels; “hypertrophy” [extreme growth]
and increase of the “neuroglia” [supporting tissue of the nervous
system].
71
Likewise, Van Deventer, in his handbook on nursing and
psychiatry (1897), indicated that paralysis was accompanied by
van dementia paralytica,” Psychiatrische en Neurologische Bladen,1908,12,9–23; G. Janssens
and J. G. Dikshoorn, “Histologisch onderzoek van een geval van paralyse, atypisch, naar de
localisatie en atypisch naar de kwaliteit van het proces,” Psychiatrische en Neurologische Bladen,
1909,13,387 –401; G. Janssens and R. A. Mees, “Een geval van progressieve juveniele
dementie,” Psychiatrische en Neurologische Bladen,1907,11,209 –22; G. Jelgersma, “Over de
histopathologische veranderingen van het zenuwstelsel bij Dementia Paralytica,” Psychiatri-
sche en Neurologische Bladen,1906,10,105 –13.
70. A. Deenik, “De genese van het paralytisch insult,” Psychiatrische en Neurologische Bla-
den,1911,15,510 –24; see also L. Bouman, “Das relative Gewicht der Grosshirnwindungen
von 25 an Dementia Paralytica verstorbenen Patie
¨nten,” Psychiatrische en Neurologische Bladen,
1904,8,199 –205; L. Bouman, “Ruggemergsveranderingen bij progressieve paralyse,” Psy-
chiatrische en Neurologische Bladen,1906,10,114 –24.
71. J. W. H. Wijsman, Voorlezingen over psychiatrie voor studenten, artsen en juristen (Amster-
dam: Scheltema & Holkema, 1896), 88.
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abnormalities in the nerve tissue and he pointed out to nurses the
physical disorders found in patients.
72
However, the various research articles and textbooks failed to have
immediate effects on clinical practice; by and large, their authors
remained silent about therapy and cure.
73
It seemed they were after
something else: through their focus on dementia paralytica they
sought to support the assumed physical causes of mental disorders.
As the Utrecht psychiatrist H. Buringh Boekhoudt pointed out in
1894, study of dementia paralytica played a paradigmatic role in the
association of psychiatry and neurology:
Its strange place as so-called organic psychosis, on account of which
both neurologists and psychiatrists consider it part of their domain,
ensures that paralysis ...will long continue to be an element of scien-
tific research. And fortunately so, because a psychosis, which can
quickly be lethal ...and cause its victim’s mental bankruptcy in no
time, is pre-eminently suited to be studied by them who seek to trace
the interconnection between anatomic abnormalities and mental dis-
ease symptoms.
74
In fact, two years later, in 1896, the Dutch Psychiatric Association
admitted neurologists and changed its name into Dutch Psychiatric
and Neurological Association.
In 1908, Meeus applauded Buringh Boekhoudt, saying “now this
was a true medical view.” By then, Meeus claimed, it had been estab-
lished unequivocally that dementia paralytica, “under a layer of psy-
chological colours,” was actually a disease “with a firm diagnosis and
prognosis, based on unchangeable clinical symptoms and fixed ana-
lytical data.”
75
In the eyes of psychiatrists who embraced laboratory
research, these findings confirmed the correctness of the neurological
shift in psychiatry. If at that point one had not produced a method of
72. J. van Deventer, Handboek der krankzinnigenverpleging (Amsterdam: Van Heteren,
1897), 81.
73. This changed only after the introduction of the Wasser mann test in 1906, which
established the connection with syphilis. See, for example: H. Klein, “Over de reactie van
Wassermann,” Psychiatrische en Neurologische Bladen,1909,13,316 –26.; J. J. P. Hilbers, “Vac-
cine en serumtherapie bij dementia paralytica en tabes,” Psychiatrische en Neurologische Bladen,
1911,15,418 –27; F. S. Meijers and J. G. Schnitzler, “De salvarsaanbehandeling bij tabes en
dementia paralytica,” Nederlandsch Tijdschrift voor Geneeskunde,1916,57/I,328 –30.
74. H. Buringh Boekhoudt, “De herkenning van dementia paralytica,” Geneeskundige
Bladen uit kliniek en laboratorium voor de praktijk,1894,1/VIII,201 –25,201.
75. Meeus, “Over ‘Dementia’,” 420.
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treatment for dementia paralytica yet, it was the very direction psychi-
atric research ought to pursue.
DEMENTIA PARALYTICA IN MODERN SOCIETY
Surprisingly, the conviction that on the basis of pathological –
anatomic research of dementia paralytica psychiatry had proved itself
to be part of medical science in general and neurology in particular,
was not reflected in the discussions on the causes of the disease con-
ducted by physicians in both the Netherlands and abroad from
around 1880. From the medical perspective, after all, it would have
been natural for them to seize upon the suspected relationship with
syphilis, discussed in the international medical community as early as
1857, to underline the somatic basis of paralysis. Initially, however,
the claim by the French dermatologist Alfred Fournier, in his La
syphilis du cerveau (1879), and by the German physician Emanuel
Mendel, in his Die Progressive Paralyse der Irren (1880), that syphilis was
the main cause of dementia paralytica hardly reverberated in the med-
ical community.
76
Although they did not deny that syphilis might be
a causal factor, for most physicians it was far from self-evident that it
was the only or even the main cause. They felt that syphilis was just
one of the causal factors and that, apart from hereditary taint and
degeneration, moral, and social–cultural influences—including alco-
holism, sexual license, extreme passions, emotions and worries, ner-
vous exhaustion as well as the pressures of modern society—played at
least an equally important role. Still, from the mid-1890s syphilis was
given a prominent place in the discussions, notably in the light of
statistical evidence with regard to the interrelation between this vene-
real disease and paralysis as well as the debate on the dangers of prosti-
tution and alcoholism for public health.
As of 1883, dementia paralytica figured prominently on the psychi-
atric agenda in the Netherlands and the Dutch discussion about this
disease was strongly influenced by medical discoveries and debates
in France and Germany.
77
AtameetingoftheDutchPsychiatric
76.Que
´tel, History,160 –62,299; Blok, Hersenverweking,35 –38; Brown, “Why Wagner-
Jauregg Won the Nobel Prize,” 373 –5.
77. S. Brosius, “Over het begin der dementia paralytica,” Psychiatrische Bladen,1883,1,
92 –103; A. O. H. Tellegen, “Discussie over de dementia paralytica, vooral in Nederland,”
Psychiatrische Bladen,1883,1,193 –225; A. O. H. Tellegen, “Nog eens de dementia paraly-
tica in Nederland,” Psychiatrische Bladen,1885,3,121 –40; A. van der Swalme,“Discussie
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Association, the asylum doctor Antonius O.H. Tellegen called upon
his colleagues to investigate the disease’s prevalence and etiology by
establishing statistics on its occurrence among their patients, supple-
mented by case histories. In his own research of paralytics from the
Coudewater asylum, he established that sixty-six of the total number of
111 were “hereditarily predisposed.” They contracted the disease either
from their parents who also suffered from dementia paralytica (or alco-
holism or nervousness) or through “indirect heredity,” meaning poor
upbringing. As possible causes Tellegen further mentioned “the amoral-
ity of cities,” theatre and opera attendance, the reading of modern nov-
els, the enhanced struggle for life as well as syphilis. A sensible hygiene
and self-discipline would potentially counter the further spread of
dementia paralytica: “One should teach young people a sense of duty
and self-control. It would certainly be desirable that people live more in
line with the Ten Commandments.”
78
The psychiatrists who responded to Tellegen’s call considered not
only syphilis but also sorrow, alcohol, heredity, and sexual debauch-
ery as causal factors. Some observed that dementia paralytica had an
above-average prevalence among certain professional groups, such as
railroad men, businessmen, factory owners, scholars, civil servants,
and in particular sailors and military men.
79
AccordingtoH.vanCap-
pelle, the last two groups consisted of “men who commonly overin-
dulge in Baccho and Venere, who sometimes suffer great fatigues and
various discomforts and who in general lead less ordinary lives.”
80
He
also noted that workers and specially farmers were underrepresented.
Like Van Cappelle, other physicians assumed a connection between the
prevalence of paralysis on the one hand and life in cities or the
over de dementia paralytica, vooral in Nederland,” Psychiatrische Bladen,1883,1,218 –25;
N. B. Donkersloot, “Bijdrage tot de statistiek der dementia paralytica in Nederland,” Psy-
chiatrische Bladen,1884,2,55 –56; W. F. Westening, “Ziektegevallen van dementia paraly-
tica,” Psychiatrische Bladen,1884,2,142 –4; H. van Cappelle, “Het voorkomen van paralysis
cerebri in de krankzinnigengestichten in Nederland in verband met de beroepen der opge-
nomenen,” Psychiatrische Bladen,1885,2,201 –24; Winkler and Wellenbergh, “Bijdrage tot
de casuı
¨stiek der dementia paralytica.”
78. Tellegen, “Discussie,” 205,217.
79. Van der Swalme, “Discussie,” Westening, “Ziektegevallen”; “Discussie tussen de
aanwezigen bij de voordracht van Tellegen ‘Nog eens de dementia paralytica in Nederland’
op de vergadering van de Nederlandse Vereeniging voor Psychiatr ie te Haarlem, 11 juni
1885,” Psychiatrische Bladen,1885,2,121 –40.
80. Van Cappelle, “Het voorkomen,” 202 –3.
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countryside on the other. It was logical, they claimed, that only few
farmers fell prey to the disease: “surely, in the current era individuals
who meet with sorrow, experience disappointments, exert their brain
andsoonwillbeaffectedinparticular.”Farmersinthequietcountry-
side doing physical work out in the open air suffered less from the ten-
sions of the hectic “present-day era.” They were “less modern” and
“less civilized,” and therefore their brains would be far less affected than
those of urban dwellers.
81
From the mid-1890s, syphilis was increasingly mentioned as a
major cause of paralysis, but not as its exclusive cause. In 1895, Telle-
gen, who had earlier minimized the role of syphilis, claimed that the
disorder was an effect of syphilis: “two diseases of the nervous system
that used to be attributed to a range of causes have to be seen as an
effect of luetic infection, namely tabes dorsalis and dementia paraly-
tica.”
82
The growing attention for syphilis was tied to the publication
of a new book by Fournier, Les affections parasyphilitiques (1894), in
which on the basis of statistical data and clinical experience he again
pointed to the connection between syphilis and paralysis. Fournier’s
insights were supported by the Austrian psychiatrist Richard von
Krafft-Ebing. In the mid-1890s, he injected nine paralytic patients
with syphilitic wound discharge, and because in the following year
six of them showed no reaction, he concluded that these patients al-
ready suffered from lues.
83
Increasingly physicians were convinced that dementia paralytica was
not possible without syphilis, but they did not exclude other causal
factors.
84
Apparently, syphilis was a necessary condition, but whether
it was a sufficient condition for the emergence of the disorder contin-
ued to be an unresolved issue. For example, Wijsman summed up var-
ious causes in addition to syphilis: “humiliations, frustrations, mood
fluctuations, extreme mental exertion, alcoholism, extravagances, iso-
lation, constant exposure to high temperatures, head wounds.”
85
In his
textbook for psychiatric nurses, Van Deventer characterized dementia
81. Ibid., 201.
82. A. O. H. Tellegen, “Het vraagstuk der geslachtelijke onthouding,” Psychiatrische Bladen,
1895,13,81 –109,90.
83. Oosterhuis, Stepchildren of Nature,91.
84. J. K. A. Wertheim Salomonson, “Boekaankondiging,” Nederlandsch Tijdschrift voor
Geneeskunde,1894,38/II,1106 –7; G. Jelgersma, “Recensie van Fournier,” Nederlandsch
Tijdschrift voor Geneeskunde,1895,39/III,1088–9.
85. Wijsman, Voorlezingen,85.
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paralytica as a disease of civilization that was tied to “the high demands
posed by contemporary society. The main cause of this suffering lies
in extreme exertion of the body and in particular of the mind, a con-
tinuous exposure to mental stimuli, alcohol abuse and several other
factors.”
86
In a report on a statistical study of the prevalence of paralysis at the
municipal asylum in Amsterdam between 1879 and 1892,VanDeventer
addressed in more detail the connection between the disease and mod-
ern civilization. Syphilis and alcohol use, in his view, were the necessary
“causal elements,” without which paralysis could not emerge, while
other causal factors directly or indirectly served as catalyst: harmful
“toxic” and “mechanical” effects on the brain, extreme exertion of the
brain and influences weakening people’s integral physical functioning,
such as a constantly raised blood pressure. In addition he distinguished
“removed” or “predisposing” causes,whichinhisviewwereheredity,
temperament, profession, age, housing and living environment, and the
struggle for life in a highly developed civilization.
87
Cox, too, assumed
that syphilitic infection was the necessary condition of dementia paraly-
tica while still not offering a full explanation. Whether a syphilis patient
would fall prey to this disease depended on whether or not hereditary
degeneration was a factor.
88
Although from 1906 it was possible to show the presence of the
syphilis microbe in the blood of paralytics, causing more experts to
assume that syphilis was a necessary condition for the emergence of
the disease, not all were convinced. Gerbrandus Jelgersma, in his
psychiatric textbook (1911), still pointed to other, indirect causes.
Syphilis constituted no sufficient explanation: the fact that not all
syphilis sufferers contracted dementia paralytica suggested, in his
view, that individual lifestyle and physical condition were as impor-
tant as the lues infection. In particular, the disorder’s more frequent
occurrence during the nineteenth century signaled that “modern
civilisation has had an enormous influence on our way of life.”
89
86. Van Deventer, Handboek,81.
87. J. van Deventer, “Bijdrage tot de aetiologie der dementia paralytica,” Psychiatrische en
Neurologische Bladen,1898,2,10 –19.
88. W. H. Cox, “Degeneratie (Eene copulativogene correlatiestoornis),” Psychiatrische en
Neurologische Bladen,1907,11,9–85.
89. G. Jelgersma, Leerboek der Psychiatrie. Eerste deel specieel gedeelte (Amsterdam:
Scheltema & Holkema, 1911), 173.
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Although psychiatrists stressed the biomedical nature of their pro-
fession, at the same time psychiatry was governed by a multi-causal
logic that assumed the interplay of various biological, physiological,
mental, and social influences, which could occur as predisposing and
inducing causes. In Dutch psychiatric textbooks that appeared from
the mid-1890s, authors described dementia paralytica as a disease
that could not emerge without syphilis infection but that was also
caused by a set of mutually reinforcing factors: biological (hereditary
predisposition), social (civilization), and individual (lifestyle and
emotions). The theory of degeneration, which assumed that acquired
features were hereditary, suggested the interplay of harmful hereditary
and environmental influences.
90
Until into the 1920s, psychiatrists
believed that the emergence of paralysis not only depended on syph-
ilis but also on other causes such as “mental overexertion” or “socio-
logical factors.”
91
That psychiatrists continued to refer to moral and social–cul-
tural factors, despite the evidence in favor of the connection
between syphilis and paralysis, was tied to their effort to broaden
their sphere of activity. Apart from a somatic explanation they
also advocated a social–hygienic approach of mental disorders,
thus claiming a social role. Their preventive approach, which for
instance was aimed at fighting alcoholism and excessive sexual
behavior, was in line with a wider social activism in the Nether-
lands at the end of the nineteenth century. This involved an
increased drive of both private organizations and the government
to tackle various social problems and inequalities, in particular the
“social issue,” and to elevate the masses in a moral sense.
92
At
that time many saw the spread of syphilis as tied to “immorality”
in general and prostitution in particular. Initially most physicians
were proponents of regulation of prostitution through police and
90. On the influence of the theory of degeneration in European psychiatry, see: Sander
L. Gilman and J. Edward Chamberlin, eds., Degeneration: The Dark Side of Progress
(New York: Columbia University Press, 1985); Daniel Pick, Faces of Degeneration: A Euro-
pean Disorder 1848–1918 (Cambridge: Cambridge University Press, 1989); Ian Dowbiggin,
Inheriting Madness: Professionalization and Psychiatric Knowledge in Nineteenth Century France
(Berkeley: University of California Press, 1991); J. Tollebeek, G. Vanpaemel, and K. Wils,
Degeneratie in Belgie
¨, 1860–1940: een geschiedenis van ideee
¨n en praktijken (Leuven: Universitaire
Pers Leuven, 2003).
91. L. Bouman and B. Brouwer, Leerboek der zenuwziekten: Algemeen gedeelte (Haarlem:
de Erven F. Bohn, 1922), 345.
92. Oosterhuis and Gijswijt-Hofstra, Verward van geest,56–64,207 –21.
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medical surveillance, as it had evolved in the course of the nine-
teenth century. This was based on the notion that prostitution
was a necessary evil (because the irrepressible male sexual drive
required an outlet), so the harmful after effects in the form of
venereal diseases had to be kept under control. In the last decade
of the nineteenth century, however, there was growing resistance
in society against regulated prostitution. In the 1880s, Protestant-
Christian organizations took the lead in the fight against prostitu-
tion, which was seen as source of immorality and syphilitic infec-
tion. The “abolitionists” also reacted against the double standard
that legitimized regulation: because middle-class women should
not fall victim to male lust, men had to look for sexual gratifica-
tion among women from the lower classes. In part because of the
rejection of this moral ambivalence, which created different stan-
dards for men versus women and for middle-class versus working-
class women, also feminists, social-liberals, and socialists turned
against regulated prostitution.
93
Next, an increasing number of physicians spoke up against regu-
lated prostitution. Although in the Netherlands the fear of the popu-
lation’s degeneration such as through hereditarily transmitted syphilis
did not grow to equally large proportions as for instance in France,
worries about public health increased among physicians.
94
Tellegen,
for example, argued that sexual self-control was necessary because
syphilis was as “a source of all sorts of ailments ...the largest risk ...
for the population, the family and the individual.” The medical class
should “not co-operate in fostering immorality.”
95
Tellegen’s views,
which were shared by other psychiatrists, can explain in part—aside
from psychiatry’s multi-causal explanatory model—why they held
on to social and moral influences as causal factors in the etiology of
dementia paralytica. In line with the growing social activism and the
93. A. Mooij, Geslachtsziekten en besmettingsangst: Een historisch-sociologische studie 1850–
1990 (Amsterdam: Boom, 1993), 30–34,44 –55,62 –63; G. Hekma, Homoseksualiteit, een
medische reputatie: De uitdoktering van de homoseksueel in negentiende-eeuws Nederland (Amster-
dam: Sua, 1987), 149 –64; P. Koenders, Tussen christelijk re
´veil en seksuele revolutie. Bestrijding
van zedeloosheid in Nederland, met nadruk op de repressie van homoseksualiteit (Leiden: PhD diss.,
Rijksuniversiteit Leiden, 1996), 47–94. On the moral purity movement see also:
D. J. Noordam, “Getuigen, redden en bestrijden. De ontwikkeling van een ideologie op
het terrein van de zedelijkheid, 1811–1911,” Theoretische Geschiedenis,1996,23,494 –518.
94. Oosterhuis and Gijswijt-Hofstra, Verward van geest,207–14; see also Dowbiggin,
Inheriting Madness and Nye, Crime, Madness, and Politics.
95. Tellegen, “Het vraagstuk,” 90,107.
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progressively stronger moral purity movement in Dutch society, psy-
chiatrists wanted to have, apart from their medical –clinical task, also
a social–hygienic task. For this reason, they pointed to the public
health risks of prostitution and other sexual debaucheries.
CONCLUSION
The psychiatric interpretation of dementia paralytica took on three
forms in Dutch psychiatry around 1900, depending on the context
in which psychiatrists practiced their profession and pursued their
professional aspirations: (1) the view from the asylum; (2) theories
drawn from patho-anatomical study; and (3) the perspective of those
engaged in social debates about sexuality, disease, and mental illness.
Clinical practice in the asylum, as the patient records from the
St. Elisabeth Hospital show, centred on the need to care for invalid
and incurable patients and to control their unruly and restless con-
duct. Therapy was no option (at least until the 1920s) and therefore
paralytics did not fulfill the medical aspirations of psychiatrists such
as Cox and Le Ru
¨tte. Still, the records from the late 1890s reveal an
increasingly standardized and objectified medical gaze. If the new
clinical focus did not change the causal explanation of dementia
paralytica and did not produce any positive effects from a therapeutic
angle, it did provide more certainty on diagnoses and prognoses. To
a certain extent this approach reflected the medical orientation in
psychiatry and the aspiration to turn asylums into hospitals. The
pathological–anatomic studies of the organic basis of dementia para-
lytica, reported by psychiatrists from the 1880s, also fitted the aspira-
tion to link up their field with scientific medicine, and neurology in
particular. Seen through the microscope’s lens, dementia paralytica
was the disorder that would allow them to present themselves as nat-
ural scientists in laboratories. At the same time, Dutch psychiatrists,
in the wake of their foreign colleagues and based on statistics and
case histories, discussed the divergent causal relationships between
dementia paralytica, syphilis, and various biological, moral, and
social–cultural factors. They also joined social debates on the moral
level of society in general and the dangers of prostitution for public
health in particular.
Our and also Blok’s conclusion differ from that of some historians
who claim that psychiatrists embraced the assumption that syphilis
caused dementia paralytica because they were eager to demonstrate
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the physical causes of mental diseases.
96
To be true, this ambition did
play a role in their approach of paralysis, but it only offers a partial
explanation. Neither do our findings support Margaret Thomson’s
suggestion that psychiatrists struggled with indications pointing to
syphilis as the cause because of the dominant Victorian morality that
tabooed open discussion of sexuality, and therefore also of syphilis. If
Dutch psychiatrists were not reluctant at all to discuss syphilis as a
causal factor, they refused to accept the idea that it was the single and
definitive cause for other reasons.
97
Our conclusions tie in with the
argument of German Berrios, George Rosen, and Gayle Davis that
nineteenth-century psychiatrists often combined natural–scientific
rhetoric with a multi-causal approach in practice. Degeneration think-
ing, which supposed a combination of heredity and environmental
factors, was in line with this approach.
98
Our findings also correspond
to those of Gayle Davis in her study on paralysis in four Scottish asy-
lums in the period between 1880 and 1930. She understands the
multi-causal approach of psychiatrists against the background of the
tensions between their daily clinical practice, their scientific ambitions,
and their broader social and moral concerns.
99
The Dutch psychiatric
approach of paralysis can be explained in a similar way.
If Dutch psychiatrists described paralysis in somatic and neurolog-
ical terms, they also employed, from a social –hygienic and partly
clinical angle, a multi-causal explanation for dementia paralytica. In
the patient records as well as in the social – hygienic discourse they
looked for the causes of paralysis mainly in emotional, moral, and
social factors. That these divergent approaches existed side by side
can in part be explained by physicians’ inability to treat the disease,
which caused the accent to shift from therapy to prevention. By
insisting on changes in lifestyle and more individual self-control, as
well as on social measures such as the fight against prostitution and
alcoholism, psychiatrists presented themselves as hygienists of society.
96.Que
´tel, History,61; Engstrom, Clinical Psychiatry,107 –10; Binneveld and Wolf, Een
Huis,35; Braslow, “The Influence of a Biological Therapy,” 580–81.
97. Margaret S. Thompson, “The Wages of Sin. The Problem of Alcoholism and
General Paralysis in Nineteenth Century Edinburgh,” in The Anatomy of Madness III, ed.
William Bynum and Roy Porter (London: Tavistock, 1988), 316–41; cf. Blok, Hersenver-
weking,78–80.
98. Berrios, “Depressive Pseudodementia”; Rosen, Madness in Society,247 –58; Davis,
“The Cruel Madness of Love,”199–231; see also Blok, Hersenverweking,81 –83,89 –90.
99. Davis, “The Cruel Madness of Love,” 239 –45.
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Another possible reason why they held on to a multi-causal explana-
tion is perhaps their fear that they would lose their authority on
paralysis if it was established that the cause was exclusively somatic and
that therefore the disease fully belonged to the domain of neurology or
internal medicine. Also, and more in general, Dutch psychiatrists were
attached to multi-causal explanations of mental disorders: in order to
distinguish themselves from other doctors whose expertise was somatic,
they created a distinct profile as experts who were able to interrelate
somatic, mental, and social–cultural factors. In clinical practice, as can
be observed in patient records, they usually followed a descriptive and
individualizing approach of patients, in a more or less intertwined
fashion.
100
Dementia paralytica, then, played an ambiguous role in the devel-
opment of the psychiatric profession in the Netherlands. For asylum
doctors with therapeutic aspirations, so the patient records from the
St. Elisabeth Hospital and also those of the Willem Arntsz Hospital
reveal, paralysis was hardly a disorder that allowed them to boost their
medical identity. Conversely, to physicians who performed scientific
research and cherished academic ambitions, paralysis served to sup-
port the argument that psychiatry should follow the example of sci-
entific medicine. The social–biological view of dementia paralytica
as a degenerative disorder of modern civilization legitimized psychi-
atric participation in the social –hygienic fight against “immorality”
and other wrongs in society.
100. Oosterhuis and Gijswijt-Hofstra, Verward van geest,195 –207,241 –2.
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