by Helmuth Steinmetz, University Hospital/Goethe University Frankfurt, Germany
I. Founding fathers of the 19th century
Today’s neurology would not have developed and is unthinkable without the close interaction that took place among our European forefathers as early as in the 19th century. The following Germans were among the most important of these pioneers.
Romberg, Erb and Wernicke
“The term neurologist indeed dates from 1832, the year that Romberg introduced the work of Charles Bell to his Berlin audience.” [Viets 1948] Born in 1795, Moritz Heinrich Romberg translated the first edition of Sir Charles Bell’s anatomic book on “The Nervous System of the Human Body” into German. Adopting Bell’s and Francois Magendie’s distinction between motor and sensory nerves and spinal root portions, Romberg was the first to formulate an analytical structural-functional approach towards examining and understanding disease-related dysfunction, mainly of the peripheral and spinal nervous system. “Neurology as we know it today, in practice and in clinic, developed only after he published the first edition of his “Lehrbuch der Nervenkrankheiten”, the first volume in 1840 and a final one in 1846.” [Viets 1948] An influential English edition was issued in 1853 in London.
Moritz Heinrich Romberg (1795 - 1873)
Born in 1840, Wilhelm Erb possibly “was the most brilliant clinical neurologist of the latter part of the nineteenth century”. [Viets 1948] After having gained experience in pathology and internal medicine, and stimulated by teachers such as Friedreich and Duchenne, Erbs’s further work was mainly devoted to spinal and muscular disorders, but also to electrotherapy. He was among the first who regularly used the reflex hammer. He clearly stated the need for neurological specialization and education. Thus, “perhaps his greatest gift to neurology was in the field of teaching, for it is to Erb we owe the development of an orderly and systematic manner of examination, so fundamental to diagnosis”. [Viets 1948] Among his scholars were Adolph Struempell, Max Nonne and Johann Hoffmann.
Different from the originally trained “internists” Romberg and Erb, Carl Wernicke, born in 1848, came from the field of psychiatry. Accordingly, his main interest was the analysis and understanding of brain dysfunction. Shortly following Broca’s observations published in 1861, Wernicke further conceptualized “topic” models of higher-order dysfunction such as aphasia. He envisioned that these might hopefully be able to later unify neurology, psychology and psychiatry. Other than this premature expectation, the developing “neurological surgery” benefitted particularly from his way of thinking. Wernicke’s most important scholars were Otfried Foerster, Kurt Goldstein and Karl Kleist.
Carl Wernicke (1848-1905)
Two mothers: Psychiatry and Internal Medicine
Although neurology in Germany emerged from both internal medicine and psychiatry, it remained part of primarily psychiatric institutions in most German universities and hospitals until the second half of the 20th century (“Psychiatrische und Nervenkliniken”). This differed from the English or French speaking countries of Europe and America and also stood in contrast to the considerable number of internationally renowned “pure neurologists” in Germany before the world wars. Recognizing the need for their specialization and self-organization, a group around Hermann Oppenheim 1906 wrote the following statement that became the “birth certificate” of today’s German Neurological Society: “Neurology still lacks the acceptance of its independence in universities and hospitals. We need an association of German neurologists representing their interests.”[cited after Karenberg in Koempf (Ed) 2007] Shortly thereafter, at the age of 67, the great teacher Wilhelm Erb became the first president of the “Gesellschaft deutscher Nervenaerzte” founded 1907 in Dresden.
II. Further successful years before 1933
The success story of the founding fathers of the 19th century was continued in the early 20th century by the next generation of similarly creative and influential neurologists. All of them had in common that they started to utilize emerging new methods providing previously unimagined insights into brain structure and dysfunction. In fact, their discoveries fall into a truly “golden age” of neurology in Germany [Karenberg, Eckart in Koempf (Ed) 2007; Kolle (Ed) 1956, 1959, 1970].
Alois Alzheimer and histopathology
Born in 1864, Alois Alzheimer was among the first to use microscopy of stained postmortem brain slices for the study of neuropsychiatric conditions. Together with Franz Nissl, he histologically characterized progressive paralysis, arteriosclerotic brain damage and, in 1906, another “peculiar affection of the cortex” later named after him by Emil Kraepelin. Alzheimer was confident that tissue characterization, but not functional localization, would prove to be the key to a better understanding of brain disorders. To him belongs much of the merit of having unraveled the organic nature of the dementing conditions and to distinguish between them. It should be kept in mind that today’s clinical classifications followed the histopathological ones, not vice versa.
Alois Alzheimer (1864 - 1915)
Cecile and Oskar Vogt, Korbinian Brodmann and brain architecture
It was 1898 in the laboratory of Pierre Marie in Paris where the 28 year-old Oskar Vogt met his later wife Cecile Mugnier, one of the first female neurologists in history. Back in Berlin, joined by Korbinian Brodmann, they started to use serial whole-brain sections to microscopically delineate cortical areas, thalamic and striatal nuclei and their fibre connections (“cyto- and myeloarchitectonics”). Complementing these anatomic studies with electrical stimulation of cortical fields (in apes) the Vogts showed that structural borders coincide with physiological ones and vice versa, a finding simultaneously confirmed for the human cortex by their contemporary Otfried Foerster during the 1920ies in Breslau (Wroclaw). The Vogts assumed that their concept of structural-functional “topistic units” might also explain patterns of damage in genetic, toxic or metabolic disorders, something one might refer to as “selective vulnerability” today.
Korbinian Brodmann, Cecile Vogt, Oskar Vogt, Max Borchert, Max Lewandowsky, circa 1903
Hans Berger and the electroencephalogram
“Indeed, I believe to have found the electroencephalogram of man and hereby publish this for the first time” were the famous words written by 56 year-old Hans Berger in 1929, 5 years after his original recording. Having entered the Psychiatry Clinic in Jena 1897, at that time led by Otto Binswanger, Berger’s goal had always been the objective measurement of “psychic energy”. First studies in cats and dogs were followed by direct recordings from the human brain surface during open surgery, and in 1924 from the scalp. Partly due to Berger’s secluded scientific lifestyle, it was not before 1934 that the English physiologist Edgar Adrain recognized the importance of his observations, also lending the name “Berger rhythm” to what Berger had described.
Hans Berger (1873-1941)
Neurology and World War I
Tragically, the importance and autonomy of neurology in Europe was strengthened considerably during and after the Great War 1914-1918. This was particularly so in Germany where neurology had remained integrated in psychiatric institutions in most universities and hospitals since the 19th century. The main reason for this unforeseen “consolidation” was the large number of patients surviving shots to the head acquired in the trench. Specialized institutions were opened (“Hirnverletztenheime”) allowing better care but also detailed examination of patients suffering from the sequelae of focal injury of the nervous system. One of the best-known German compilations of neurological knowledge so obtained is probably Karl Kleist’s map of the localization of cortical functions published in 1934.
III. The years 1933-1945 and their aftermath
Following a “golden century” that had started with Moritz Heinrich Romberg in 1832 German neurology entered its dark age in 1933. Legislation implemented by the “Nazi“ party banned many Jewish fellow citizens including physicians from their professions and from using their possessions. One third of the German physicians were Jewish. This led to the turnout of many, if not the most of the nationally and internationally renowned German neurologists (as well as other physicians, scientists, artists, etc., see Table). But this was not the only devastating consequence of a radically racial and “eugenic” policy in Germany between 1933 and 1945 that remained unopposed by a silent majority - and also put medicine on a “slippery slope”. As a prelude to what followed, many university chairs and other leading positions were filled politically, and neurology and psychiatry were “reunified” in 1935. Deeper historical analyses of the subsequent ethical collapse have been and are still being conducted also by today’s German neurological and psychiatric societies.
Exodus: Some of the neurologists forced out of Germany [from Peiffer 1998]
The “Euthanasia” programme
Simultaneously with the beginning of World War II, Adolf Hitler personally initiated the planning and organization of systematic killings of chronically hospitalized neuropsychiatric patients. Children and adults living in mental homes and suffering from “schizophrenia, epilepsy, encephalitis, idiocy, paralysis, Chorea Huntington, senile dementia or other final neurological states, able to perform mechanical work only” were registered in a semi-governmental office in Berlin. Based on these paper records, each patient was graded “+” or “-“ by three “reviewers” from a group of 40 neurologists and psychiatrists, all explicit “eugenicists” and members of the Nazi party. After the transportation of their victims to dedicated killing facilities throughout Germany, approximately 70.000 “lives unworthy of life” were extinguished between January 1940 and August 1941 in gas chambers, by starving or injections. This secret “Aktion T4” was stopped by Hitler in August 1941, partly due to leaking information and resulting public protests from church officials. However, the operation had provided core personnel and “experience” for what followed immediately thereafter, the Holocaust.
Criminal experiments in human patients
Not suprisingly, the mental framework of this grim period also lowered the ethical standards and thresholds for some neurological studies in human patients. One such example are the ”Schaltenbrand experiments” carried out in 1940/1941. Georges Schaltenbrand, chairman and professor at Wuerzburg University, believed that multiple sclerosis was an infectious disorder with a long incubation period. He injected cerebrospinal fluid obtained from patients with multiple sclerosis into the subarachnoid cisterns of up to 8 human patients living in a mental home suffering from “catatonia” or “schizophrenia”. In 1943, he stated „I thought that I could take this responsibility for such studies in humans suffering from incurable total idiocy” [Peiffer 1998]. His experiments came to no final result because his patients were selected and killed during the aforementioned “Aktion T4” (without the participation of Schaltenbrand). As another prominent German neuroscientist of his time, Julius Hallervorden from the Kaiser Wilhelm Institute for Brain Research in Berlin suggested brain removals to be performed within “Aktion T4”. Thereby, he received and collected hundreds of specimens which he continued to exploit even in a number of postwar publications [Daroff 1994].
IV. Slow reorganization after 1945
After this deep fall within only 12 years, it took another two decades for German neurology to gradually regain scientific orientation, organization and international acceptance. It was a restart from almost point zero in a divided country.
Heinrich Pette (1887 - 1964)
Even though three “old” neurology chairs at the universities in Hamburg (Heinrich Pette), Heidelberg (Paul Vogel) and Wuerzburg (Georges Schaltenbrand) still existed or were reinstituted immediately, the process of emancipation of neurology as an independent field had been reversed between 1933 and 1945 (see above). Today’s German Neurological Society, originally founded in 1907 and temporarily dissolved in 1935, was reestablished not before 1950. It took until 1951 and 1955 until the first “new” neurology chairs were created in Freiburg (Richard Jung) and Duesseldorf (Eberhard Bay). Not before 1968 - and only in West Germany - a board certification for either neurology or psychiatry (or both) became available. Only since the late 1970ies every university medical school in West Germany had a dedicated neurology chair. In East Germany, the University of Leipzig remained the only academic institution with an independent neurology department established in 1965 (Peter Feudell). [Eisenberg, Wagner in Koempf (Ed) 2007]
Richard Jung (1911 - 1986)
Emancipation versus integration
During the 1950ies and 1960ies many German colleagues argued for maintaining the institutional and educational integration of neurology into psychiatry (“Nervenheilkunde”). Among their arguments were an expected lack of “enough” purely neurological patients and the importance of neurology as a scientific bridge between psychic and organic medicine. [Eisenberg in Koempf (Ed) 2007] Finally, this intensive dispute was not solved by arguments but mainly by neuroscientific progress that started to speed up in the 1970ies and simply required further specialization in the emerging methods of clinical electrophysiology, neuroimaging, neuropharmacology, neurointensive care, etc. Growing numbers of neurological patients, increasing therapeutic options and the material prosperity during and after the German ”economic miracle” further contributed to a final, but relatively late re-emancipation of neurology in (West) Germany.
Gustav Bodechtel (1899 - 1983)
Re-emerging “schools” after 1945
The gradual recovery of neurology in the early postwar period was driven by only a few local neurological “schools” and key figures. Heinrich Pette, chairman in Hamburg-Eppendorf since 1934, remained a particularly important teacher in the initial phase. He also was the first president of the German Neurological Society reinstituted in 1950. Among Pette’s successful scholars of the 1950ies were Gustav Bodechtel (later Munich), Rudolf Janzen (Dortmund, Hamburg), Werner Scheid (Cologne), Helmut Bauer (Goettingen) and Hans-Georg Mertens (Wuerzburg). These descendants of the “Hamburg school” later became the academic teachers of Adolf Schrader (Munich), Friedrich Erbsloeh (Gießen), Albrecht Struppler (Munich), and Hanns Christian Hopf (Mainz), to mention only a few. Already starting in the 1950ies, the spectrum of neurology was increasingly broadened by scientific and methodological inputs from experimental and clinical neurophysiology. Particularly influential pioneers of this development were Richard Jung (“Freiburg school”) and Albrecht Struppler (Munich), with many of their scholars still being active today. Richard Jung became the first president of today’s German Society of Clinical Neurophysiology and Functional Imaging originally founded in 1950 under the name “Deutsche EEG-Gesellschaft”. Just as Pette in the late 1950ies, Jung and Struppler also constituted dedicated neuroradiology sections within their neurology departments and strongly promoted functional neurological surgery. Neurovascular ultrasound was among the methods specifically elaborated in Freiburg, and Struppler performed functional stereotaxy himself until well after his retirement. It was this generation and the return to scientific mind-openness that began to pave the way for today’s (re-)internationalization of German neurology.
Helmut Bauer (1914 - 2008)
Albrecht Struppler (1919-2009)
V. Some future perspectives (as they appear in 2015)
The last three decades have seen scientific, diagnostic and therapeutic breakthroughs that our forefathers weren’t even able to imagine. Crucial for this success was and will continue to be the internationalization of neurology and an ongoing worldwide exchange between us. Based on its own history the German Neurological Society remains particularly committed to this goal.
Growing importance of brain health
The number of neurological patients will continue to grow during the upcoming decades. For Germany and Europe, Parkinson’s disease, disorders leading to dementia, and stroke are among the medical conditions with the shortest expected “doubling times”. In addition to the exciting diagnostic and therapeutic progress made, this epidemiological perspective currently contributes to a steadily growing number of neurologists not only in Germany. It seems that they will face increasing challenges and demands for research, treatment, prevention, care and teaching.