Historical review: a short history of German neurology - from its origins to the 1940s

This paper aims at reconstructing the development and role of German neurology between 1840 and 1940. Therefore a couple of original sources as well as selected material form the scattered secondary literature were assessed and reviewed. Since the middle of the nineteenth century, an intricate process of separation from internal medicine and psychiatry gradually led to forming a self-conscious community of German neurologists. While Moritz Heinrich Romberg had constructed a cognitive basis for neurology, scientific founders such as Wilhelm Erb, Carl Wernicke, Alois Alzheimer, Hermann Oppenheim, Max Nonne, and many others established the new discipline within modern medicine. In 1891, the first generation of “pure” neurologists succeeded in founding the German Journal for Neurology (Deutsche Zeitschrift für Nervenheilkunde) followed by an autonomous professional organisation, the Society of German Neurologists (Gesellschaft Deutscher Nervenärzte) in 1907. A variety of external factors, however, hampered the institutional evolution and thus the implementation of chairs and departments remained quite modest. In 1935, only 2 years after the National Socialists had seized power, the regulatory merger with the psychiatristsʼ society caused the cautious attempts of German neurologists for autonomy to end in complete failure. The imprisonment, murder and expulsion of neuroscientists declared as Jewish or non-Aryan caused profound changes in neurology, medicine, academic life, and health care in general. Further historical research is needed to reconstruct in detail the involvement of German neurologists in racial-hygienic and eugenic research as well as the institutional and scientific development of German neurology after World War II.

Dental care in modern art (1914-2014)

Background Representations of 'dentists in action' in modern art have never been systematically researched. This paper surveys and analyses these portrayals for the first time.Methods Relevant paintings, prints, sculptures, and installations were identified by means of keyword searches in search engines, OPACs and picture libraries as well as handsearch.Results Between 1914 and 2014 more than 75 works of art with dental treatment as a motif appeared across the globe. Virtually every modern style from post-impressionism to 'crossover art' are represented, including world famous artists such as Dubuffet or Dalí. Syringes, Doriot's transmissions and contra-angle handpieces are worked into an iconographic code. In contrast, elements of an increasing hygiene consciousness (gloves, face masks and protective glasses) are integrated only fragmentarily. The dentist-patient relationship is predominantly portrayed professionally and realistically and the stereotype of the male dentist dominates.Discussion For almost a century it has been argued that dentists in action had largely disappeared from artistic production after 1900. The results presented here force a revision of this idea and encourage the further discovery of pictorial sources. Only in this way can the fascinating theme of 'dentistry in art' become an attractive part of dental humanities.

[German neurology and neurologists during the Third Reich: Preconditions and general framework before and after 1933]

This article focuses on the institutional development of neurology in Germany up to the rise to power of the National Socialists and the radical sociopolitical changes after 1933. A wide range of scattered secondary literature was assessed and evaluated. Additionally, some original sources are literally quoted and interpreted according to the context. Since the end of the nineteenth century a complicated process of separation from internal medicine and psychiatry led to the formation of a self-conscious discipline of neurology. The first generation of German neurologists succeeded in founding the German Journal for Neurology ("Deutsche Zeitschrift für Nervenheilkunde") in 1890 and their own neurological association, the Society of German Neurologists ("Gesellschaft Deutscher Nervenärzte", GDN) in 1907. On an international scale, however, the institutional implementation of neurology with only a small number of chairs and few neurology departments remained more than modest. The ambitions for autonomy ended 2 years after the change of power in 1933. Regulatory interventions by the government and psychiatric interests led to the fusion of the GDN with the psychiatric specialist society, the new association being called the Society of German Neurologists and Psychiatrists ("Gesellschaft Deutscher Neurologen und Psychiater", GDNP) in 1935. In this group psychiatrists dominated the discourse. The expulsion, imprisonment and murder of physicians declared as non-Aryan or Jewish along with the forced consolidation ("Gleichschaltung") at the universities prompted profound changes in medical and academic life. It remains an ongoing challenge of neurological historical research to measure the impact of this upheaval on the few neurology departments in hospitals and private practices.

[German neurology and neurologists during the Third Reich: brain research and "euthanasia"]

The connection between systematic killing of the mentally ill and disabled, euphemistically called "euthanasia" in the National Socialism ideology, and German brain research has been thoroughly investigated and in detail; however, the impact of this criminal nexus on the image and self-perception of German neurologists as well as the status of neurology as a medical discipline is still the subject of controversial debates.Between 1939 and 1945 the Kaiser Wilhelm Institute (KWI) in Berlin along with other research centres were insofar enmeshed in the "euthanasia" program as brains of killed patients were dissected in the guise of "concomitant research" in order to generate medical knowledge. Affected were mainly individuals suffering from oligophrenia, early childhood brain atrophy, cerebral palsy and epilepsy. According to current historical research, collegial networks were instrumental in receiving brains of killed patients. Furthermore, civil research units were supplemented by military ones at the KWI. These, too, were concerned with the collection of medical knowledge, for instance on injuries of the brain and spinal cord. The historical approach to consider the Nazi organizations and medicine as "resources for each other" seems, therefore, at least in part applicable to neurology.

[A short history of thrombosis: concepts and therapies from ancient to modern times]

BACKGROUND

Historians of thrombosis usually cover a period from mid-19th to late 20th century, thus highlighting the era of scientific progress. The present study, however, follows history farther back to its earlier stages which harbour crucial elements for understanding later epochs and the present-day state of the art.

METHODS

Relevant primary sources and secondary material as well as selected illustrations were identified and interpreted in their historical context.

RESULTS

Early concepts drew upon the doctrine passed on by the Greeks that thrombosis originated form "metastases" formed by phlegm and black bile. Whereas scholars of the Middle Ages concerned themselves with haematoscopy as a "prototype" of diagnostic investigation, those of early modern times focused on mechanistic and morphological factors when formulating aetiological concepts of thrombosis and embolism. With Rudolf Virchow and his consolidated findings the modern age of positivist research began. During the following era of technological progress, new and scientifically tested treatments as well as prophylactic interventions replaced empirically based cures.

CONCLUSIONS

The history of thrombosis is characterized by a multitude of different paradigms. Time will tell if innovative therapeutic strategies developed during the last two decades will lead to the next important paradigm change.

Wilhelm Fabry's 1614 report on a giant condyloma of the penis

For many years it has been the work of Buschke and Löwenstein that has justified calling the exophytic, locally destructive tumour of the anogenital mucosal surface 'giant condyloma of Buschke and Löwenstein' or GCBL. In order to investigate the early history of this rare disease we examined the writings of the barber-surgeon Wilhelm Fabry (1560-1634) who had a serious interest in dermatological disorders and their treatment. We analysed Fabry's 600 Latin case reports and identified the case of a 'monstrous penile tumour'. We then translated this text into English and compared it point by point with later publications. This was followed by a cursory review of surgical treatises from the 16th to the 18th centuries. In 1614 Fabry described and depicted a tumour of the penis; the clinical characteristics (gradual formation of a warty lesion, considerable size, invasive growth, absence of metastases) indicated it was a giant condyloma. His mention of the urethral fistulization enables discrimination from 'common' condylomata acuminata, and the survival period of 10 years after amputation allows exclusion of a 'true' carcinoma. This report is singular among 17th-century case histories. The neoplasias described 300 years later are most probably biologically identical. Thus, Fabry's is the first clinical report; the histological classification, however, belongs to Buschke and Löwenstein. From now on the disease should be designated with the eponym giant condyloma of Fabry-Buschke-Löwenstein or GCFBL.

[Personality in old age]

Modern developmental psychology tends to draw a positive, resource-based picture of human aging. We will however focus on more difficult aspects of personality in old age which are of psychiatric relevance: the persistence of cluster A and C personality disorders, antisocial personality in the elderly; the interaction of personality and a detection of mild cognitive impairment (MCI); personality features as risk or protective factors or early signs of Alzheimer's dementia; changes of personality in Parkinson's disease and frontotemporal dementia. We will briefly mention recent neuroimaging studies which appear to suggest a functional neuroanatomy of personality. A quote from Cicero's cato major, de senectute indicates that some of his perceptions regarding classic personality characteristics of the elderly can be recognized in our patients and can be prevented or treated with modern interventions.

[The portrayal of multiple sclerosis in television series]

BACKGROUND

An increasing number of television series deal with neurological disorders, including fictional portrayals of multiple sclerosis (MS). The aim of this paper was to analyze every available TV episode with an MS character.

MATERIAL AND METHODS

Productions were identified by film databases and by hand search. Each episode was evaluated along neurologic and cinematic lines.

RESULTS

Between 1985 and 2006, portrayals of MS appeared in 17 episodes produced in Germany, the US, and the UK. The frequency of symptoms shown onscreen strongly differed from epidemiological data. In particular sensory, cognitive, and bladder symptoms as well as difficulties with sexual function were under-represented. The authenticity of the disease depiction was strongly dependent upon the genre. Coping stories could be identified as the most prominent genre. Television patients were often portrayed as "brave fighters", "refined characters", and "afflicted without symptoms".

CONCLUSIONS

Television series attract millions of viewers and thus shape the public image of a disease. Sound knowledge of how symptoms, diagnosis, and therapeutic options are presented in mass media is therefore indispensable for all who deal with MS patients, relatives, and caregivers.

Retrospective diagnosis: use and abuse in medical historiography

Medical papers on diseases of famous persons, sometimes called pathographies, constitute the by far largest section of publications dealing with historical diagnosis. The procedure of attaching modern diagnostic labels to illustrious personalities of the past, i.e. retrospective diagnosis, has stimulated an ongoing theoretical debate among clinicians and medical historians. The purpose of this paper is to clarify some of the issues involved. Key problems of retrospective diagnostics are reviewed and analysed. In addition, the case history of the Polish composer Fryderyk Chopin is used to highlight problems and pitfalls of this method. Whereas contemporary physicians are used to apply present-day nosological categories to individuals of the past or historical epidemics, medical historians are more cautious to do so. They argue that in the absence of definite proofs retrospective diagnoses often are nothing more than mere speculation. Another important counter-argument is that medical knowledge itself varies over time and historical changes in nosology must not be ignored. Future pathographies should use primary sources extensively, focus on historical context and minimize the pursuit of retrospective diagnoses or causes of death. Only with a fundamentally revised method, a more critical approach to retrospective diagnostics, and far more serious objectives will medical biographies be in a position to break new ground.

Headache in magical and medical papyri of ancient Egypt

Despite the intensity with which many scholars have studied the evolution of Egyptian medicine, interdisciplinary studies on the history of headache are scarcely extant. Following a short discussion of historiographical issues, the main objective of this paper is to present a comprehensive and detailed overview on this subject. Scattered references to headache are extracted from so-called magical papyri and from medical texts of the New Kingdom. Although little is known about the quality of headache and about accompanying symptoms, four predominant localizations are distinguished. Due to the lack of precise descriptions it is impossible to establish the retrospective diagnosis of migraine. Explanations of the origin of cephalalgia and of the corresponding therapeutic actions differ according to the nature of the source. In magical papyri, headaches are attributed to the action of demons and supernatural forces, whereas medical papyri emphasize the role of head trauma and of 'pain matter' occurring in the body. Treatment could be magical, pharmacological or surgical. Examples of incantations and prescriptions are analysed in detail.

[Early history of Pick's disease]

The development of the concept of Pick's disease can be divided into three periods. From 1892 on Arnold Pick reported a series of patients presenting cognitive disturbances, personality changes and focal symptoms such as aphasia and apraxia. Pick, however, like his contemporaries, did not conceive of a new nosological entity. The major event during the second period was the outline of histological characteristics like argentophilic inclusion bodies by Alois Alzheimer. During the 1910s however, Alzheimer's extremely important observation remained unnoticed. Further historical research is necessary to clarify why Alzheimer's subtype of dementia was hurriedly regarded as a disease, whereas Pick's was not. Political factors such as Kraepelin's strategic considerations seem to have played an essential role. In accordance with major research criteria of German neuropsychiatry, Pick's atrophy was constructed as a full-blown disease entity in the 1920s. This concept gained acceptance in the German and Anglo-American scientific community and was the starting point for further investigations in the 1950s and 1960s.

Medieval descriptions and doctrines of stroke: preliminary analysis of select sources. Part I: The struggle for terms and theories - late antiquity and early Middle Ages

This first of a series of papers on the history of stroke presents an examination of a number of exemplary Greek and Latin sources, ranging from late antiquity to the dawn of the Middle Ages. We first establish a chronological order of various groups of texts and, whenever possible, ascertain the relationship of one group of writings to another. In the second century A.D., Galen had used the Hippocratic concept of humoral imbalance as a fundamental explanatory mechanism for the interpretation of clinical manifestations of apoplexy. Galen definitely rejected the Aristotelian precept of the primacy of the heart. According to his teaching, stroke resulted from the accumulation of a thick and dense humor in the ventricles of the brain blocking the passage of the animal spirit. Galen's Greek texts became axiomatic for compilers of the Byzantine period (Aetius of Amida, Alexander of Tralles, Paulus of Aegina). But his ideas contrasted starkly with the theories of the Methodical School which exerted - through the Latin writings of Caelius Aurelianus - a certain influence on authors of the Latin West (Cassius Felix, Theodorus Priscianus). References to stroke can also be found in many theological writings of the early Middle Ages.

Medieval descriptions and doctrines of stroke: preliminary analysis of select sources. Part II: between Galenism and Aristotelism - Islamic theories of apoplexy (800-1200)

This second paper on medieval descriptions and doctrines of stroke reviews concepts outlined by famous Muslim physicians of the Middle Ages such as Rhazes, Haly Abbas, Avicenna, and Averroes. Contrary to a popular belief, Islamic neurological texts represent not only a bridge between ancient and western medieval medical knowledge, but also document remarkable advancements. Whereas statements on diagnosis and prognosis lack originality, the endeavors of physician-philosophers and medical authors led to substantial additions and important changes in theory. Such modifications include the integration of ventricular doctrine and particularly the attempt to unify Aristotelian and Galenic tenets which resulted in a complex discussion about the seats and causes of apoplexy. The fairly simple model handed down by Galenists of the Byzantine period was replaced by more detailed classifications, which proposed "cerebral" as well as "vascular" origins of the disease without suggesting a "cerebrovascular" etiology. Islamic therapeutic strategies included dietetic, pharmacological and surgical elements. The use of the cautery in "chronic apoplexy" was a special feature of Arabic surgery.

Medieval descriptions and doctrines of stroke: preliminary analysis of select sources. Part III: multiplying speculation - the high and late Middle Ages (1000-1450)

By analyzing a body of texts compiled by various medical authors from the 11th to the 15th century, four basic developments can be noted: (1) From the beginning of the eleventh century the reception, translation and assimilation of Arabian and arabicized ancient texts became the ultimate goal of Western medicine (Constantine the African, Arnad of Villanova, et al.). Concepts of stroke were consequently guided by textual tradition, not by observation. (2) Scholastic speculations about different aspects of apoplexy, especially those concerning its origins, were numerous (Johannes Platearius, Batholomaeus Salernitanus, Pietro d'Abano, Giacomo da Forli). Although most medieval physicians used the ancient doctrine of the four humors as model and explanation, opinions differed in many ways. (3) Attempts developed to present a simple outline of the etiology, the prognosis, and the treatment of the disease (Gilbertus Anglicus, Bernard of Gordon, John of Gaddesden). (4) Although lacking in originality, many of these writers nevertheless achieved a certain uniformity in presenting main topics, thus setting the standard for later practitioners.

[Johann Jakob Wepfer's book on apoplexy (1658). Critical comments on a classic in neurology]

The Swiss physician Johann Jakob Wepfer has been hailed as the author of the "classic" modern treatise on apoplexy (1658). His name is known because he demonstrated that apoplexy resulted from brain hemorrhage or occlusive diseases of the vessels. A re-examination of the original text, however, reveals surprising evidence that essential parts of Wepfer's book have been neglected so far. These chapters demonstrate that Wepfer's medical thinking is deeply rooted in pre-modern concepts, e.g. Galenic theories of brain function and iatrochemical concepts of disease. A re-evaluation of the non-modern elements of Wepfer's treatise leads to a better understanding of the whole text.

[Apoplexy in ancient medical writing]

To a certain degree, the history of neurology can be conceptualised as a history of important diseases related to the nervous system. Although most of these disorders were either first discovered or classified on an anatomical and physiological basis after 1800, early descriptions of neurological symptoms and theories about their origin date back to the medical literature of antiquity. Using the case study approach, this paper reviews ancient concepts of apoplexy from the 5th century BC to the 5th century AD. Based on medical texts of more than 20 authors (e.g. Hippocratic writings, Aristotle, Diocles, Praxagoras, Celsus, Aretaeus, Soranus, Galen, Caelius Aurelianus), definitions of the disease, clinical symptoms, prognosis and differential diagnosis are described first, succeeded by a discussion of the hypotheses on aetiology and pathogenesis. Special emphasis is placed on the key principles of ancient medicine such as the doctrine of the four humours, the concept of the pneuma and the theory of the "communicates" and their explanatory power for neurological disorders. The following chapter is dedicated to classic therapeutic strategies. The paper concludes with a brief survey on the influence of ancient concepts on authors of later centuries.

[Acute paraparesis in chronic hepatic disease]

An acuta caude equina syndrome following portacaval shunt in a 64-year-old patient suffering from liver cirrhosis is reported. Diagnosis of a hepatic radiculopathy was confirmed by clinical and electrophysiological findings. A nearly complete remission of the neurological symptoms was achieved by treatment of the primary liver disease. Since there are only a few descriptions of severe hepatic polyneuro- and radiculopathies, the differential diagnosis of hepatic myelopathy is discussed.

[Why does the human immunodeficiency virus (HIV) invade the nervous system?]

Human Immunodeficiency Virus (HIV) has neurotropic effects that are independent of the well-known lymphotropism. They have been proved by various techniques, but their pathogenesis is not clear. It is remarkable that the neuropathological features do not correlate with the degree of the clinical symptomatology. HIV antigens and antibodies are demonstrable within the central nervous system by immunological tests. The macrophages transport the virus across the blood-brain barrier and are responsible for its persistence in that location. Different cell types, especially of the subcortical areas, have HIV-receptive CD4 molecules. These markers may be identical with the receptors for endogenous neuropeptides and it is likely that viral proteins are causing a competitive inhibition of these mostly neurotrophic factors. This interference is discussed as one of the main reasons of HIV dementia.

[Symptomatic mania in HIV infection. 3 cases of classified euphoric psychoses as a sequela of the AIDS disease]

3 case histories of patients with acquired immune deficiency syndrome and acute organic psychoses are reported. Their psychoses can be classified as benefaction or blissfulness psychoses. A handfull of previous reports classify similar acute organic psychoses as symptomatic manias. The respective descriptions make obvious that these psychoses are homogenous among each other and that their contents represent a vivid reflection over a life situation which had been thoroughly changed by the AIDS illness.

[Psychopathologic pictures in HIV infection: AIDS lethargy and AIDS dementia]

The paper describes the psychiatric status on the basis of 76 patients with acquired immune deficiency syndrome. There is considerable difference between the different stages of the disease. The disorders are divided into groups following the German and French psychopathological tradition, where the incidence is dependent on the underlying complaint. 50% of the patients suffered from chronic psychoorganic disorders (34% organic personality disorders, 16% dementia). 9% suffered from an acute psychosis caused by complications and founded on substantial physical illness. 3 patients showed symptoms of a (under given circumstances) hitherto unknown endoform psychosis. In 9% of the patients, psychoreactive disturbances (anxiety and reactive depression) were observed. Two infants had congenital development deficiencies. 25% of the patients were without any psychopathology. Patients showing organic personality disorders mostly resemble each other to such a degree as to form a separate group. We suggest to name this group according to the most prominent psychopathology as "AIDS-lethargy". This status is characterised by a specific apathy, tiredness and indolence of the patients combined with the lack of emotional participation related to their own destiny. AIDS-lethargy is the first manifestation in appearance of the HIV infection of the brain itself. Another sequel of the brain infection is AIDS dementia which can be classified as "subcortical dementia" and differs from the more current forms of dementia clinically. Affected are mainly neuropsychologic functions like arousal, attention, mood and motivation, whereas the hallmarks of cortical involvement-aphasia, agnosia and apraxia-are not present. Supplementary findings (EEG, CCT, CSF): The group of patients with chronic psychoorganic disorders differs significantly from the group with psychoreactive disorders and normals. Pathological EEG and CCT are more frequent in psychoorganic disorders. CSF-test-including the intrathecally synthesized antibodies against HIV-does not show traceable variation in either group. There are four problems which may be combined in a given acute psychopathological HIV-syndrome: 1. Being member of a risk group with its reactive, psychosocial and personality problems. 2. Individual mental and emotional reaction to the fact of infection 3. Chronic psychoorganic disturbances. 4. Acute organic psychoses as a result of complications and other physical illness.

Acute encephalitis with intrathecal synthesis of measles antibodies

In two cases of acute encephalitis, there was an intrathecal antibody synthesis against measles virus, as determined with an enzyme-linked immunosorbent assay. The clinical findings were not consistent with a usual measles infection, subacute sclerosing panencephalitis or acute multiple sclerosis.

[Multiple brain infarcts in zoster infection]

The clinical, CSF, CCT and PET findings in a 14-year-old female patient are reported. CCT and PET investigations demonstrated multiple cerebral infarctions; CSF examinations revealed inflammatory changes. Zoster antibodies were synthesized intrathecally, as detected by an ELISA after adjusting serum and CSF to identical IgG concentrations. Therefore the diagnosis of a cerebral zoster angiitis was made. Diagnostic and therapeutic problems of inflammatory vascular lesions are discussed.

[Disorders of glucose metabolism in Pick's disease]

A clinically diagnosed case of advanced Pick's disease served to illustrate that positron emission tomography is a sensitive method for diagnosing complex functional disturbances. Pick's disease can be differentiated against presenile dementia represented by Alzheimer's disease in that the pattern of reduced metabolism characteristic of Alzheimer's disease is different from that of Pick's disease where in accordance with the clinical syndrome the glucose metabolism in the frontal and temporobasal regions in reduced, involving also the structures of the hippocampus and an equally significant reduction of glucose metabolism in the caudate nucleus. Especially during the initial phase of the disease when structural changes are not yet evident or the clinical manifestation of the syndrome does not correlate with the degree of lobar atrophy seen in the computer tomogram or via magnetic resonance tomography, positron emission tomography can make differential diagnosis much easier.