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Localization and Its Discontents
A Genealogy of Psychoanalysis and the Neuro Disciplines
By Katja Guenther The University of Chicago Press
Copyright © 2015 The University of Chicago
All rights reserved.
ISBN: 978-0-226-28834-5
CHAPTER 1
In the Morgue
Theodor Meynert, Pathological Anatomy, and the Social Structure of Dissection
In 1913 the German psychiatrist and philosopher Karl Jaspers identified three "prejudices" in psychopathology that "weigh[ed] ... with paralyzing effect" on the field: the somatic, the philosophical, and the "absolutizing." Of the three prejudices, the first was particularly vicious, producing what had been called "brain mythologies." In making his criticism, Jaspers had a particular form of the somatic view in mind: the theory of functional localization, or Zentrenlehre. Neuropsychiatrists in the nineteenth century had asserted the existence of sensory and motor "centers" in the brain, and they sought to map out the parts of the cortex dedicated to certain functions such as language. For Jaspers, however, this approach was based on a deeply problematic rationale: "These anatomical constructions ... became quite fantastic (e.g. Meynert, Wernicke) and have rightly been called 'Brain Mythologies.' Unrelated things were forcibly related, e.g. cortical cells were related to memory [Erinnerungsbild], nerve fibres to association of ideas. Such somatic constructions have no real basis. Not one specific cerebral process is known which parallels a specific psychic phenomenon."
Jaspers criticized here the apparently direct translation process between psychological and anatomical categories. It was not that he denied the interdependence of mind and body; he maintained that bodily phenomena, such as digestion, were influenced by mental phenomena and, conversely, that mental phenomena "originate[d] in part from somatic sources." But in no case did he think that "some specific psychic event [was] directly associated with some specific somatic event." The simple one-to-one translation was, to Jaspers, an uncritical, "unreal" one.
Jaspers's critique was marked by his larger project. In line with his later existential philosophy, Jaspers denied that there was a "uniform theoretical framework" of psychopathology and, by extension, subjectivity. Unlike the sciences, which "rest[ed] on comprehensive and well-founded theories," such as atomic theory or cell theory, no theory for psychology or psychopathology had such a sure foundation. To Jaspers, then, not only was there no solution to the translation problem; the very attempt to provide psychology with a coherent theory (based on its relationship with physiology, or any theory at all) was misguided. Psychologists should strive rather for a pre-theoretical understanding.
In questioning the process of translation between psychological and anatomical categories that was constitutive of the Zentrenlehre project, Jaspers identified its central difficulty and limitation. In fact, as we will see in this chapter and the next, the process of translation was inherent to the practice upon which the Zentrenlehre was based, and the proponents of the very tradition that Jaspers attacked recognized it as a problem. But because it was a problem that they confronted directly, we should not see the translation between psychological and physiological categories as an uncritical one. Neuropsychiatrists did not simply map psychological functions onto brain anatomy. Rather, this mapping was conditioned by the institutional, practical, and social context of hospital medicine, especially in Vienna in the mid-nineteenth century. In navigating this context, the neuropsychiatrists developed complex and innovative strategies for bridging the apparent divide between the psychological and the somatic aspects of their work. Further, while Jaspers saw the difficulty as sufficient reason to reject the somatic approach wholesale — a critical attitude that was further developed in the interwar neurological "holism" of Kurt Goldstein and Henry Head — the neuropsychiatrists attempted to address its problems. Indeed the most important criticisms, institutionally and intellectually, of the neuropsychiatric tradition came from within. As we will see over the course of this book, the developing disciplines of neurology, neurosurgery, and even psychoanalysis are the results of such engagement; rather than external criticisms like Jaspers's, they are better understood as internal reformulations.
Somatic Medicine in Vienna
The neuropsychiatric attempt to correlate mental pathology with lesions in different parts of the brain participated in a broader turn to the somatic in modern medicine. As Michel Foucault has prominently (if somewhat schematically) argued, the nineteenth century saw a dramatic shift in medical practice, what he calls a transformation of the medical "gaze" (regard). Gone was the old classificatory system that provided a hierarchy and family tree of diseases, where each was defined in relationship to the others. Location in the body, rather than location within a classificatory system became the structuring principle of the new nosology. In the earlier model, a disease could migrate, manifest itself across a range of symptoms, and metamorphize over time, while symptoms allowed a disease to "show through." But such migrations and metamorphoses were no longer possible in the new medicine, where pathology was related to a lesion located in a particular organ. In the new system, the disease was, in Foucault's words, "entirely exhausted in the intelligible syntax of the signifier." That is to say, the lesion was the pathology, rather than being merely an effect of it. Connected to this new form of medicine was the conviction that, given the appropriate tools, all pathologies could be found in the body, that one could see a disease fully, and that it could not elude the eye of the doctor forever. Pathological anatomy practiced on bodies in the mortuary became the privileged way to access disease and learn about it.
In The Birth of the Clinic, Foucault structured his narrative around a transformation in Paris at the turn of the nineteenth century. In this period, the French capital attracted medical students and doctors from all over the world. But by 1840, Vienna came to rival Paris as a magnet for aspiring young doctors. The "Second Vienna Medical School" followed in many ways its French counterpart. From midcentury until about 1890, Viennese medicine was dominated by a new somaticist paradigm promoted by Carl von Rokitansky (1804–1878), the first Ordinarius of pathological anatomy in Vienna (and later rector of Vienna University), and his collaborator, the internist Josef von Skoda (1805–1881).
Rokitansky presented the new somatic method as a scientific response to both a vitalistic Naturphilosophie and an unrigorous clinical method. It was the second that was the most pressing concern at the beginning of his career. Rokitansky identified its central problem: "The same symptom complex was caused by very different material changes." He insisted that diagnoses would find a surer foundation through a study of "the changes of material substrates perceptible to the senses." This could be achieved through the pathological anatomical method, which, as he pointed out in the preface to his three-volume Handbuch der pathologischen Anatomie of 1846, had the potential to become the new basis for medical theory and practice.
Rokitansky's aspirations for pathological anatomy did not immediately translate into institutional centrality. Indeed, at the time he wrote his Handbuch, pathological anatomy was relatively marginal in the Vienna medical landscape. True, since the 1820s it had been an independent discipline, having wrestled itself free from internal medicine, of which it had, under the auspices of Johann Peter Frank (with Aloys Vetter as prosector), been an ancillary specialty. But independence was not tantamount to prominence. The old pathological anatomical building (Alte Prosektur) was a simple structure in the northern part of the hospital area (see fig. 1.1, top); a visitor in 1847 described it as rather "pathetic barracks." Apart from a storage space for dead bodies, the institute consisted of merely two rooms, "a larger one for the dissections of those who died in the asylums and a smaller one for the forensic dissections." Rokitansky complained about the equipment and lack of heating. The Prosektur, he grumbled, was "well suited to ruin permanently the health of everyone working there."
Rokitansky's early career was marked by steady progress through the ranks of a relatively marginal field. In 1827, when still a medical student, he accepted a post as unsalaried intern (Praktikant) at the Prosektur, where he became assistant in 1830. Not long thereafter, he was promoted to Extraordinarius in pathological anatomy (1834), then a decade later to Ordinarius (1844). By the middle years of the 1840s, Rokitansky had become a big fish in a small pond, destined, it seemed, for an honorable if not particularly illustrious career.
That all changed after the abortive revolutions of 1848. In quick succession Rokitansky gained a number of prestigious administrative and public posts (without, however, giving up his work in pathological anatomy). The following year, he was made dean of the medical school. In 1853 he became the first freely elected rector of the University of Vienna. Outside of the university, too, he was seen as a man on the rise: he became president of various learned societies, including the Imperial Academy of Science in July of 1848 and the Anthropological Society in 1870. In 1863 he became medical adviser to the Ministry of the Interior and was nominated by the emperor to the High Chamber of the Royal Council.
Rokitansky's ascendence after 1848 can in part be explained by the political and cultural changes in postrevolutionary Vienna. Before the revolution he had often been considered apolitical, and this reputation served him well in the immediate wake of the revolution's suppression, when change at the political level remained elusive. Rokitansky's particular brand of liberalism — which is evident in his speeches from the period — placed faith in science as the motor of human progress, valuable both for the production of wealth and for overcoming class differences. In this way, it conformed to the norms of the moment. Much of the liberal energy from the Vormärz period was redirected after 1848 to cultural and social pursuits. Among other things, the Academy of Fine Arts (Akademie der bildenden Künste) was reorganized by Count Franz Thun, new construction projects were undertaken, and the period saw a great rise in associational activity, with the formation of numerous Vereine and artistic groups.
Of all the post-1848 projects, the one that perhaps left the greatest mark on the city was the Ringstrasse. After 1848, the Hofbaurat was dissolved, and proposals were invited for a new development in the location of the former city wall. Although none of the winning proposals were in the end implemented fully — instead the emperor chose a modified version drawing on several, in order to respond better to military concerns — the plan was accepted in 1859 and work began shortly after. The planning compromise was fitting; combining entrepreneurial spirit with authoritarian rule, it showed the Ringstrasse to be a child of its time.
Rokitansky's rising prominence was mirrored by the status of pathological anatomy. As a sign of its importance, the old "barracks" were replaced by a "splendid building," in the words of a contemporary, to house Rokitansky's new Pathological Anatomical Institute (fig. 1.1, bottom). It is significant that plans for the institute participated in the broader enthusiasm for renovation that came with the building of the Ringstrasse. Indeed, the new institute was built at the same time by Ludwig Zettl, the author of one of the winning proposals for the large urban renewal project. In both designs Zettl projected bourgeois self-confidence. In his plan for the Ringstrasse, he had lined the main boulevard with privately owned houses, bringing the city's wealthiest families into the center of the newly designed city. Further, the grand design of the Pathological Anatomical Institute reflected his faith in science and material progress.
The Ringstrasse project raised the profile of Rokitansky's institute in another way. Whereas before, the General Hospital lay outside the city walls, now it was merely a block away from the new center of town. At the same time, Rokitansky's specialty of pathological anatomy had come to assume a central position within the hospital. Although in the same location as the former barracks (in the north part of the "corpse yard" [Leichenhof], directly adjacent to the clinics at the General Hospital), the new institute was substantially larger and could serve as a meeting place for physicians from the hospital's other departments. In addition to rooms for the storage of cadavers; rooms for scientific and legal dissections, pathological chemistry, and microscopy; and exhibition space for rare pathological specimens, the new building also furnished "working premises" (Arbeitslocale) for pathological anatomists, forensic anatomists, and clinicians from the internal, surgical, ophthalmological, and obstetric departments. In this way, physicians like the dermatologist Ferdinand Hebra, the forensic pathologist Jakob Kolletschka, and the surgeon Franz Schuh, as well as gynecologists, ophthalmologists, and pediatricians, came to the institute to cooperate with Rokitansky, following the pathological anatomical method. The new pathological institute, a true "model institution" in the words of one commentator, served, then, to connect the various medical specialties. This unifying role was all the more important given the size and sprawling nature of the hospital. As one observer suggested, the "complex of buildings, ... deserve[d] to be named a small city given its dimensions and number of inhabitants."
Somaticizing Psychiatry
Psychiatry participated in the general trend toward somaticization, both in Vienna and in the German-speaking world more broadly. The Prussian psychiatrist Wilhelm Griesinger (1817–1868) formulated the battle cry of a new, somatically informed psychiatry when, in his 1845 opus magnum Die Pathologie und Therapie der psychischen Krankheiten, he asserted that "mental disease" was "brain disease." Griesinger's program influenced a whole generation of students in the 1850s and 1860s across the German-speaking lands. Figures like Theodor Meynert, Carl Westphal, and Bernhard von Gudden took Griesinger's dictum to heart. They thought they could differentiate between mental diseases more effectively through the study of pathological anatomy and thus provide, as they saw it, a scientifically grounded nosology.
In Vienna, Theodor Meynert (1833–1892) became one of the key proponents of the new somatic psychiatry. In 1867, along with his colleague Maximilian Leidesdorf, he founded the first specialist journal of psychiatry, which foregrounded their somaticist credentials. The journal's full and unwieldy title was Vierteljahresschrift für Psychiatrie in ihren Beziehungen zur Morphologie und Pathologie des Centralnervensystems, der physiologischen Psychologie, Statistik und gerichtlichen Medizin (Quarterly for psychiatry and its relations to the morphology and pathology of the central nervous system, physiological psychology, statistics, and forensic medicine). A year later, Meynert, Leidesdorf, and Joseph Gottfried Riedl founded the Verein für Psychiatrie und forensische Psychologie, which manifested a similar orientation.
Like Rokitansky, Meynert built his career out of the dissection room. As a medical student in Vienna, he worked in the histopathology laboratory of Carl Wedel, producing pathological specimens. Although after his Promotion (doctoral dissertation) in 1861, Meynert held a number of clinical positions — as Aspirant in internal medicine and surgery at the Vienna General Hospital in 1861, and as Sekundararzt in Gumpendorf near Vienna in 1865 — it was clear that his interests lay elsewhere. During this period, he dedicated his free time to studying the anatomy of the nervous system. He received the necessary material through various sources: his brother-in-law Scheuthauer, assistant to Rokitansky, gave him access to corpses from the Institute of Pathological Anatomy; Theodor von Oppolzer and Maximilian Leidesdorf allowed Meynert to examine the brains of their psychiatric patients after they had died; in addition, Meynert had the opportunity to work with the brains of dead animals from the Vienna zoo.
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Excerpted from Localization and Its Discontents by Katja Guenther. Copyright © 2015 The University of Chicago. Excerpted by permission of The University of Chicago Press.
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