Hungarian Psychiatry, Society and Politics in the Long Nineteenth Century: Psychiatry’s Dual Monarchy (Mental Health in Historical Perspective) 3030857050, 9783030857059

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MENTAL HEALTH IN HISTORICAL PERSPECTIVE

Hungarian Psychiatry, Society and Politics in the Long Nineteenth Century Emese Lafferton

Mental Health in Historical Perspective

Series Editors Catharine Coleborne, School of Humanities and Social Science, University of Newcastle, Callaghan, NSW, Australia Matthew Smith, Centre for the Social History of Health and Healthcare, University of Strathclyde, Glasgow, UK

Covering all historical periods and geographical contexts, the series explores how mental illness has been understood, experienced, diagnosed, treated and contested. It will publish works that engage actively with contemporary debates related to mental health and, as such, will be of interest not only to historians, but also mental health professionals, patients and policy makers. With its focus on mental health, rather than just psychiatry, the series will endeavour to provide more patient-centred histories. Although this has long been an aim of health historians, it has not been realised, and this series aims to change that. The scope of the series is kept as broad as possible to attract good quality proposals about all aspects of the history of mental health from all periods. The series emphasises interdisciplinary approaches to the field of study, and encourages short titles, longer works, collections, and titles which stretch the boundaries of academic publishing in new ways.

More information about this series at https://link.springer.com/bookseries/14806

Emese Lafferton

Hungarian Psychiatry, Society and Politics in the Long Nineteenth Century

Emese Lafferton Department of History Central European University Vienna, Austria

ISSN 2634-6036 ISSN 2634-6044 (electronic) Mental Health in Historical Perspective ISBN 978-3-030-85705-9 ISBN 978-3-030-85706-6 (eBook) https://doi.org/10.1007/978-3-030-85706-6 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Cover illustration: Photo of the paper model of the ‘Lipótmezo Royal Mental Institution’ made by unknown inmate treated at the institution, 1917 (photo by Péter Hámori). Psychiatric Art Collection of the Hungarian Academy of Sciences. This Palgrave Macmillan imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

To Lili and Beni, the centres of my universe, without whom this book would have appeared a decade earlier. To my Mother and Father, with the deepest gratitude.

Acknowledgements

This book is long overdue. Many things postponed the completion of an old project: the vicissitudes of temporarily anchored post-doc life, the exploration of new academic cultures, the preparation for courses and other teaching duties at different universities, the irresponsible straying away to novel research areas, and eventually the arrival of children. But at last, triumphant over the COVID pandemic with isolation, online teaching and home-schooling, the book is finally out. Now I wish to acknowledge institutions that made this possible and thank those individuals who helped me or offered their invaluable friendships throughout my long journey. I am greatly indebted to the three supervisors who helped the work which formed the basis of this book. Sadly, two of them are no longer with us. I am forever grateful to Roy Porter who accepted me as his supervisee as an unknown student from Hungary, based on a single paper I sent him and he liked. Thanks to him, I spent a year at the Wellcome Institute for the History of Medicine in London where I fell in love with the history of medicine and science. His guidance and support were invaluable. After Roy’s death, the two people who helped my work are the late John Forrester with his curiosity and zeal for anything related to the mind and Susan Zimmermann—now wonderful colleague at Central European University—with her intellectual scrutiny and sensitivity to issues of inequalities.

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The Wellcome Trust generously funded my post-doc fellowship (RG35883) I spent at the Department of History and Philosophy of Science at the University of Cambridge. I then continued as a lecturer at the Science Studies Unit at the University of Edinburgh before I returned to Budapest with a Marie Curie Fellowship and eventually became a part of the faculty at my alma mater, the Central European University (since then the university was expelled from Hungary for political reasons and re-settled in Vienna). From all these years, I want to thank many valued friends and colleagues for inspiring me through conversations, the discussion of parts of my work, organising workshops, planning courses or research, offering help in difficult times, or just being there to have a sip of wine at the right moment. These include: Martin Edwards, Sharon Messenger, Chandak Sengoopta and Natsu Hattori from the year in London; Jim Secord, Martin Kush, Nick Hopwood and Hubertus Jahn who were greatly supportive over my years in Cambridge; Wendy Faulkner, Steve Sturdy, Robin Williams, Ivan Crozier, Anna Greenwood, John Henry, Emma Frow and Isabel Fletcher, who proved to be nice colleagues in Edinburgh, and James Wood and João Rangel de Almeida from the fantastic group of Ph.D. students there without whom my time in Edinburgh would have been far less colourful and enjoyable; Andreas-Holger Maehle, Matthew Eddy and Lutz Sauerteig from Durham University where I spent a short research fellowship. I am also grateful to other colleagues and friends from different places and times, including: László Perecz, Mónika Nagy, Mónika Perenyei, Kati Evans, Robert J.W. Evans, Mitchell Ash, Sonia Horn, Deborah Coen, Anna K. Maerker, Simon Werrett and Andrew Zimmerman. I would also like to acknowledge and thank the assistance of librarians and archivists at different institutions, including the Széchényi National Library, the Library of the Hungarian Academy of Sciences, the Central Statistical Office, the (already closed) Library and Archives of the Lipótmez˝ o National Mental Institution, the Library of the Clinic of Psychiatry and Psychotherapy at the Semmelweis Medical University in Budapest, the Josephinum in Vienna and the Wellcome Library and the British Library in London. A great deal of my original research was conducted at the Semmelweis Library and Archives of the History of Medicine in Budapest, one of the most beautiful, cosy and intimate small libraries with an incredibly helpful and friendly group of librarians and historians of medicine. I wish to thank them, especially Lívia Kölnei,

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Katalin Kapronczay and László András Magyar for their warm and helpful attitude and great knowledge they were willing to share. I am grateful to my current colleagues at the Central European University for a wonderful environment to work in, but especially Nadia Al-Bagdadi, Matthias Riedl, László Kontler, Gábor Klaniczay and Balázs Trencsényi, who trusted and supported me at crucial moments in my career. I owe many thanks to Ádám Mézes who helped with the notes, text, images and bibliography of the manuscript with his soothing calmness and offered company at the lonely and tiresome last phase of clearing it. I feel fortunate to have a wonderful group of friends who have provided unceasing support, inspiration and camaraderie over decades by now. Ágnes Csonka, Sarah Dry, Tatjana Buklijas and Gayle Davis have remained great friends and comrades as well as examples of successful female scholars or intellectuals with families and children. I am indebted to Simon Schaffer for his inspiration, encouragement and help over many years. As people who know him can tell, history and research are much more fun if one can share it with him. Finally, I am deeply grateful to Viktor Karády, the most generous person I know both as a scholar and as a friend, for his time, helpfulness, wisdom and invaluable pieces of advice on both text and life. It is beyond my capacity to ever return his help. At last, I wish to thank my family, my brother Zsolt Lafferton and my sister-in-law, Barbara Ottó for their support and patience. I dedicate this book to my two young children, Lili and Beni, who had to suffer an often-stressful mother over the past months but who will hopefully one day appreciate this work. And to my parents, who raised me in the most caring and safe environment and who let me go far, freely, to find my own path, never stopping supporting me. I am grateful for their love. Two articles and a book chapter were formerly published from this project. For shorter versions of Chapters 7 and 8, see: “What the Files Reveal. The Social Make-Up of Public Mental Asylums in Hungary, 1860s–1910s,” in ‘Moderne’ Anstaltspsychiatrie im 19. und 20. Jahrhundert - Legitimation und Kritik (Medizin, Gesellschaft und Geschichte— Beiheft 26). Ed. by Heiner Fangerau and Karen Nolte, 83–103. Stuttgart: Franz Steiner Verlag, 2006, and “The Hygiene of Everyday Life and the Politics of Turn-of-the-Century Psychiatric Expertise in Hungary” in: Psychology and Politics: Intersections of Science and Ideology in the History

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of Psy-Sciences. Ed. by Anna Borgos et al., CEU Press, Budapest—New York, 2019, 239–254. For the book chapter, see: “From Private Asylum to University Clinic: Hungarian Psychiatry, 1850–1908,” in Framing and Imagining Disease in Cultural History. Ed. by George S. Rousseau, Miranda Gill, David B. Haycock, and Malte Herwig, 190–213. New York: Palgrave Macmillan, 2003.

Contents

1

Introduction

2

Histories of Psychiatry and the Hungarian Model The Self-Image of Late-Nineteenth-Century Psychiatry Histories of European Psychiatry The World Without Psychiatry Therapeutic Asylums and Moral Treatment Academic Research and Biological Psychiatry The Hungarian Model Care for the Insane in Hungary from the Late-Eighteenth to the Middle of the Nineteenth Century Medical Teaching and Professional Forums Boom in Psychiatric and Medical Institutions (1860s–1920) Modern Scientific Research and Professionalisation (1870s–1920)

3

The Bourgeois Family World of the Private Asylum: The Schwartzer Enterprise from 1850 The Schwartzer Dynasty The Private Asylum Pólya’s Asylum Schwartzer’s Asylum

1 19 19 23 23 28 33 35 37 47 58 67 101 102 104 104 105

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Laboratory of the Human Body and Soul: Schwartzer’s Comprehensive Theory of Mental Illness in Context Enlightenment and Romantic Traditions in the Culture of Austro-Hungarian Medicine Aetiology of Mental Illnesses in Schwartzer’ Theory The Therapeutic Asylum Physical Treatment Moral Treatment Doctor and Patient Conclusion: The Schwartzer Psychiatric Enterprise 4

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The Kingdom in Miniature: Public Mental Asylums from the 1860s Asylum Life Under Four Directors, 1868–1920 Life Conditions, Nursing and Treatment The Use of Coercion and Restraint Legal Regulation Versus Reality of Admission, Discharge and Guardianship in Asylums and Psychiatric Hospital Wards Medical and Bureaucratic Criteria and Conditions of Admission The Double System of Admission and Guardianship The University Clinic and the Birth of Biological Psychiatry. Academic Research, Teaching and Therapy from the 1880s Self-Perception. Teaching and Research in the Making of the Psychiatrist The Medical Context of Nineteenth-Century Scientific Psychiatry Károly Laufenauer and the Establishment of the Department of Mental Health and Pathology and Its Related Clinic Laufenauer’s Observation Ward and the Mad Strangler at Saint Roch Hospital The Split and Move of the Clinic Academic Research by Károly Laufenauer and Károly Schaffer Neuro-Anatomy, Neuro-Pathology and Brain-Histology Hypnosis Studies

109 110 116 126 126 128 131 135 147 152 152 160

165 166 171

193 194 196 201 204 211 213 213 220

CONTENTS

The Integrative Function of the University Clinic in a Fragmenting Profession 6

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Fragmenting Institutional Landscape. Alternatives of Specialised Institutions, Colonies and Family Care on the Turn-of-the-Century The Relationship of Academic and Asylum Psychiatry Old Problems, New Ways. Alternatives to the Mental Asylum “Annex Asylums” Family Care and Colonies Small Specialised Institutes for “Imbeciles” and “Idiots,” Epileptics, Alcoholics, Nervous Patients, and Criminals Asylum Statistics and the Psycho-Social Reality of the Hungarian Kingdom Social Parameters of Asylum Populations Gender and Age Distribution Marital Status and Religious Affiliation Religion Social and Professional Status The “Medical Parameters” of Asylums Problematic Taxonomy Admission Categories of Mental Disorders Discharges Invading the Public and the Private: The Hygiene of Everyday Life, Shell-Shock and the Politics of Turn-of-the-Century Psychiatric Expertise Shifts in the Social Functions of Psychiatry by the Turn of the Century Degeneration, Social Problems and Prophylactics Neurasthenia or Nervous Exhaustion Paralysis Progressiva and Female Emancipation Alcohol Problems, Class and Crime Darwinism, Lamarckism and Elements of Eugenic Thinking Shell Shock and Traumatic Neurosis Artúr Sarbó and the Theory of Micro-Structural Changes Ern˝o Jendrássik’s Degenerationist Understanding of War Neurosis

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245 245 249 251 254 263 291 296 296 303 305 308 313 313 318 319

329 329 330 332 334 337 340 344 346 347

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Viktor Gonda’s “New Electroshock Therapy” at the Rózsahegy Hospital Sándor Ferenczi and the “Discovery of the Psyche”: The Psychoanalytical Approach 9

Conclusion

349 352 369

Bibliography

385

Index

423

List of Figures

Fig. 3.1

Fig. 3.2 Fig. 3.3 Fig. 4.1

Fig. 4.2

Bath-house at Schwartzer’s Private Mental and Nerve Institution (Photo) (Ottó Babarczi Schwartzer, Prospect der Privat-Heilanstalt für Gemüths und Nervenkranke zu Budapest [Budapest: Druck von Viktor Hornyánszky, 1897]) Garden scene at Schwartzer’s Private Mental and Nerve Institution (Photo) (Babarczi Schwartzer, 1897) Garden scene at Schwartzer’s Private Mental and Nerve Institution (Photo) (Babarczi Schwartzer, 1897) Front picture of the Buda State Mental Asylum (Lipótmez˝ o) (Graphics) (Source Lipót Grósz, Emlékirat a hazai betegápolási ügy keletkezése, fejl˝odése, s jelenlegi állásáról , különös tekintettel a betegápolási költségekre [Memoir Concerning the Birth, Development and Present State of Our National Patient Care] [Buda: Magyar Királyi Egyetemi Nyomda, 1869]) Ground-plan of the Buda State Mental Asylum (Lipótmez˝ o) (Graphics) (Source Grósz, 1869)

106 108 129

148 150

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List of Tables

Table 2.1

Table 2.2 Table 4.1 Table 5.1

Table 7.1 Table 7.2 Table 7.3 Table 7.4

Table 7.5

Table 7.6

Number of students enrolled at the Pest Medical Faculty and Hungarian medical students at the Viennese Faculty, 1820–1850 Increase in number of beds, patient admission and Budapest’s population, 1873–1899 The turnover of the nursing Staff at Lipótmez˝ o in the year 1895 Patient admissions and discharges at Laufenauer’s observation ward at Saint Roch Hospital in 1885 and Krafft-Ebing’s observation ward in Graz in 1887 Annual admission and average daily number of patients at Lipótmez˝ o Public Mental Asylum (1868–1904) Gender distribution of patients treated in the asylums in the observed period Age distribution of patients at admission compared to the population of Hungary by gender Age distribution of mental patients and paralytics at admission compared to the population of Hungary by gender above 15 years of age Age distribution of mental patients excluding paralytics at admission compared to the population of Hungary by gender above 15 years of age Marital status of patients in mental asylums as compared to the general population (in per cent)

49 60 157

205 297 298 300

300

302 304

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LIST OF TABLES

Table 7.7

Table 7.8

Table 7.9 Table 7.10

Table 7.11 Table 7.12 Table 7.13

Table 7.14 Table 7.15 Table 7.16

Mental patients by religion in Dualist Hungary as compared to the total population of the country (in per cent) Denomination of patients in the Nagyszeben Asylum (1863–1913) compared to that of theTransylvanian population (in per cent) Social status of patients admitted to the Schwartzer Asylum (1850–1864) Social status of patients admitted to the Budapest Private Mental and Nervous Institutes during 1853–1885 (in per cent) Hungarian mental patients in the dualist period by professional status (in per cent) Occupations of women patients in Lipótmez˝ o with independent income (in numbers) Distribution of patients suffering from various mental illnesses in the Schwartzer Asylum by gender (1851–1863) Patient admission broken down by disease forms at Lipótmez˝ o and Nagyszeben Asylums Proportion of paralytics among male patients at Nagyszeben broken down for decades Discharges in the various mental asylums

306

307 309

309 310 312

315 316 318 319

CHAPTER 1

Introduction

The beginning of the breakdown of our old political world, among other things also of the Globus Hungaricus, is deeply injuring our narcissism. It is a good thing that one has a Jewish and a psychoanalytic ego along with the Hungarian, which remain untouched by these events. (Sándor Ferenczi to Sigmund Freud, 4 October 1918)

“Globus Hungaricus” (in the words of the Hungarian psychoanalyst Sándor Ferenczi) nicely recalls “globus hystericus,” the name given to a psychiatric disorder accompanied by the symptoms of difficulty in swallowing and a sense of suffocation. Some political and social facts of the pre-1918 old regime, such as growing national movements of the ethnic minorities, anti-Semitism and social conflicts following speedy urbanisation and poverty were perhaps just as difficult to swallow for the citizens of the Austro-Hungarian Monarchy as was its collapse, a collapse which Freud and Ferenczi anticipated in their long correspondence from the very start of the First World War. The Austro-Hungarian Monarchy’s old world was a crucible of psychology, social theory and artistic ferment. Marked by decadence, political crisis and social disintegration, it was nevertheless a place where much of modern art and thought were born. But if Central Europe is in many ways the geographic unconscious of the modern mind, Hungary is certainly the repressed other in histories of psychiatry and culture. While © The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 E. Lafferton, Hungarian Psychiatry, Society and Politics in the Long Nineteenth Century, Mental Health in Historical Perspective, https://doi.org/10.1007/978-3-030-85706-6_1

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the Viennese achievements are well-studied and appreciated, Budapest was also a place of extraordinary intellectual blossoming and artistic innovation, far less emphasised in this context. The limited focus on Vienna and on Freud’s “discoveries” not only conceals the roots of psychoanalysis by obscuring the mental asylum and a variety of other psychiatric/ psychological projects, but also dismisses Budapest and other Central European cities’ own modernist achievements as well as the salience of the Habsburg dilemma1 shared by both Austria and Hungary. A detailed history of Hungarian psychiatry in the long nineteenth century will thus offer novel insights into the Central European crisis and its unique impact on culture and science. This monograph provides the first comprehensive study of the history of Hungarian psychiatry between 1850 and 1920 placed in both an Austro-Hungarian2 and a wider European comparative framework. The geographic focus of my original research falls on the distinctively multicultural Hungarian Kingdom then inhabited by more than a dozen ethnic groups and encompassing territories now belonging to Romania, Serbia, Croatia, Austria, Slovakia and Ukraine, in addition to Hungary. With a uniquely interdisciplinary approach, the book captures the institutional worlds of the different types of psychiatric institutions intertwined with the intellectual history of concepts/theories of mental illness, and the micro-historical study of everyday institutional practices and doctor-patient encounters specific to these institutions. It grasps the ways in which psychiatrists gradually organised themselves and their profession, defined their field and role, claimed expertise within the medical sciences, lobbied for legal reform and the establishment of psychiatric institutions, fought for university positions, and for the establishment of departments and specialised psychiatric teaching. All of these were central to their claim for disciplinary integrity, cultural authority, and the monopolisation of medical knowledge and power over their clientele. Yet this story is more than one of increasing professionalisation; it also captures how psychiatry became invested in social critique. It shows how psychiatry gradually moved beyond its closely defined disciplinary borders and increasingly became a public arena. Psychiatrists extended their professional expertise, originally focused on the individual person and the psychiatric patient population, to the larger social domain, encompassing crowds, masses, cities and the nation. They did this through publications on grave social problems mostly of the urban milieu, such as alcoholism, prostitution, crime, poverty, but also on the impact of industrialisation,

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of modern lifestyle and the exhaustion of one’s vital powers, written for an audience much broader than the medical profession. They also gave popular science talks and participated in popular movements concerning public health issues, such as eugenics or the temperance movement. Parallel to this development, psychiatry also gradually invaded the private sphere of healthy people by constructing what a healthy mental, physical, spiritual and sexual life consists of, laying emphasis on prophylaxis. As a result, psychiatry attained a cultural monopoly over the “hygiene of everyday life” as well as the factors contributing to the “health” of society by the first decades of the twentieth century. This shift in the role of psychiatry is discussed in the rich cultural and social context of fin-de-siècle Budapest and the Austro-Hungarian Dual Monarchy. Therefore, beyond contributing to psychiatric history by exploring complex longue durée developments in a hitherto unstudied region, this book connects and enriches other areas of study as well. These include the cultural and social studies of fin-de-siècle modernity in Central Europe and the wider scholarship on the Austro-Hungarian Empire (Habsburg studies). Studying turn-of-the-century Hungarian psychiatry in the wider social, cultural, scientific and political context of the Austro-Hungarian Dual Monarchy invites an alternative to the genealogy of Central European modernism offered by Carl Schorske in his influential Fin-de-Siècle Vienna: Politics and Culture.3 Schorske’s discussion of psychoanalysis in the context of Viennese art, literature and culture at the time of the critical reformulations and subversive transformations of Austrian traditions explained the fin-de-siècle preoccupation with the psyche and the bourgeois cultivation of the self. The concentration on the psychological and the aesthetic was the result of the intelligentsia’s move away from politics marked by a decline of Austrian liberalism and rationalism and the rise of right-wing ideologies. Viennese modernism thus meant a retreat from the political, into the psychological realm, decadence and introspection. This provided the context for psychoanalysis to develop and become the theoretical or conceptual basis of modernism. Schorske used the image of the “garden” for this Vienna, both as a real blossoming garden of the city space and as the metaphorical garden of the psyche, both of which needed cultivation and provided shelter or refuge from the disturbing public and outer forces. In his book The Garden and the Workshop,4 Péter Hanák already argued for a need to extend this limited focus on Vienna to other cities of the Dual Monarchy when discussing Central European modernism, above all

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to Budapest. Hanák thus complemented the picture of Vienna as a “garden” of esoteric culture with the image of Budapest as the “workshop,” using Hungarians’ own notions of the brilliant centres where the intelligentsia gathered and immersed in creative activities: the editorial offices and cafés, and we might add the baths, too. Hanák thus contrasted Vienna’s aesthetic and individualistic culture with Budapest’s more moralistic and socially engaged approach. It is precisely this moralistic and socially occupied culture of Budapest through which Hungarian psychiatry engaged with the public world and which it actively shaped at the turn of the century. While the revolutionary cultural movements in Central Europe were a reaction to the common social and political crisis that eventually led to the Monarchy’s disintegration, Austrian and Hungarian responses emerged from deeply different civic cultures and political traditions. If the liberal—rational worldview was speedily fading and giving place to the irrational and apocalyptic in Vienna by the turn of the nineteenth century, Budapest saw a last important strengthening of liberalism in the 1890s and had a period of two decades marked by bourgeois radicalism that brought progressive forces to the fore before the First World War. If Viennese intellectuals, in the midst of their identity crisis, retreated from politics into the realm of the aesthetic and the psychological, Budapest intellectuals at the same time did an opposite move: they pervaded the social and public sphere and worked on progressive solutions in response to the specific Hungarian problems they perceived. Science and art here became public achievements, public and communal means to heal social problems. The traditional dynastic state-patriotism of the Austrian bourgeoisie can be contrasted with the modernist progressivist approach of an exceptionally multi-ethnic group of emerging radical intellectuals (with a very strong Jewish component) coming from the ranks of doctors, psychiatrists, sociologists and demographers, among others. Finally, if Viennese intellectuals’ main preoccupation focused on safeguarding the universal rights and liberties of the autonomous individual, the Hungarian bourgeoisie was more deeply anchored in the national (and nationalist) sentiment. By extending Schorske and Hanák’s terrain of cultural history and exploring the social role of late-nineteenth-century psychiatry and related medical and social disciplines, this book seeks to provide new insights into modern nationalism and major cultural innovations of the European fin de siècle.

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∗ ∗ ∗ While there is a wealth of literature in the history of psychiatry5 which focuses on specific institutions, practitioners, periods and geographic areas, more general longue durée approaches to national histories of psychiatry are much fewer in number. More general histories of English, French, and German psychiatry were written for instance by Ian Dowbiggin, Jan Goldstein, Eric Engstrom and Andrew Scull. Such an approach has the advantage of demonstrating both the synchronic embeddedness of psychiatric institutions, practices, and practitioners in the political and social milieu that surrounds them as well as the diachronic interplay of traditions and culture. In this respect, the Hungarian situation provides a compelling test case in the study of psychiatric history. Due to the relatively small scale of psychiatric institutionalisation and the brief period during which the processes took place in Hungary, its historian may offer a detailed yet systematic and comprehensive picture of the wide-ranging psychiatric institutions and trends, an account which seems almost impossible in other national contexts. The Hungarian case becomes a heterogeneous though contained experimental object for the study of the long-term exchanges between psychiatry, culture and social history. No doubt part of the significance and appeals of this material is that for so many contemporaries, and for their historians, it was precisely this set of exchanges which seemed generative of cultural modernity in Europe. Concerning Hungarian historiography of psychiatry, but also more generally of medicine and science, this book utilises modern approaches and perspectives and hence hopes to contribute to a field slowly transforming in the current years. Retrospective accounts on the early history of psychiatry by late-nineteenth-century Hungarian psychiatric professionals read as rather optimistic today.6 The “psychiatric project” was embedded in the victorious story of scientific progress, rapid social development and strengthening humanism. As a part of the larger scheme of nation-building, psychiatry was praised as instrumental in the elevation of the nation to the level of civilised European states. Historical scrutiny, and indeed, even some contemporary psychiatrists’ sharp criticism of their profession’s achievements, however, tend to undermine whiggish claims of humanitarianism and the myths of unbroken institutional and therapeutic progress. Power without knowledge was illusory, manifest not only in psychiatry’s admission of the elusive nature of mental illness and the

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impenetrability of mental processes, but also in the hard facts of the high mortality and dismissal rate of “uncured” patients from lunatic asylums, or in the not negligible condition that psychiatry was still largely marginal in both the medical and social spheres in the nineteenth century compared to the social status and influence it gradually acquired by the early decades of the twentieth century. The book thus reconstructs the early history of Hungarian psychiatry fraught with tensions over progress and therapeutic failure, over great institutional designs and financial constraints, and over the claimed mission and actual force of the psychiatric profession. The main, traditional hub of current Hungarian medical history7 is the Hungarian Society of Medical History 8 located at theSemmelweis Museum, Library and Archive 9 in Budapest. Their main publication outlet is the journal Orvostörténeti Közlemények [Communicationes de Historia Artis Medicinae]. The major strength of the journal is the publication of historical data and primary sources: places, dates, names and documents related to the biographies of famous as well as lesser-known medical practitioners, teachers and researchers and to medical institutions, such as hospitals, university faculties and learned societies. Needless to say, these contributions are extremely useful for further research. In general, the studies of the journal are overwhelmingly descriptive and less oriented towards analysis and methodological considerations. Critical reflections on the challenges that have emerged in the social sciences as well as in science studies since the 1970s are especially lacking. Analyses situating the history of medicine within social and economic history, investigating the history of the body or the construction of medical knowledge feature much less prominently as compared to approaches of a longer-standing tradition, such as more narrowly focused “biographies” of “great heroes,” institutions and modern disciplines. Apart from a few influential historians of an older generation, many of the practitioners of this more traditional style of medical history are archivists or come from a medical background. Promisingly, a new, younger generation of scholars is now also emerging who are able to combine primary source-based research with a more self-reflective and critical approach. They are not numerous and are institutionally scattered, working at different university departments, for instance, the Department of Philosophy and History of Science at the Budapest University of Technology and Economics or the departments of history at Central European University (recently moved to Vienna, but still with sizable cohort of Hungarian students) and the ELTE University. Nevertheless,

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students from these centres are expected to produce historical works in the coming years on various topics which would be fully conversant with western scholarship and will eventually transform the field in Hungary. While there is no comprehensive treatment of the more narrow field of psychiatric history in the observed period, there are topics, institutions or famous practitioners which attracted scholarly attention from different quarters. The most marked and well-researched area is the study of Hungarian psychoanalysis and the work and life of its world-famous practitioner, Sándor Ferenczi and other psychoanalysts known mostly only in Hungary. One needs to single out an early history on the relationship of Freud and Ferenczi and the rise and fall the Budapest school written, in the 1980s, by the psychiatrist Pál Harmat living abroad, which still stands as the most usable and comprehensive historical analysis on the topic.10 The most prolific writer with a historically sensitive approach is the late psychologist Ferenc Er˝ os, whose relevant short monographs, edited volumes and especially articles are just too numerous to collect here.11 From a more interdisciplinary perspective, Csaba Pléh has written numerous monographs and articles on the history of psychology in the West as well as in Hungary.12 One needs to mention the work of another psychologist, Judit Mészáros as Ferenczi’s biographer,13 and from a younger generation of scholars, the work of the psychologist Júlia Gyimesi on Ferenczi and spiritualism.14 There are numerous useful publications of sources and articles related to psychoanalysis and Ferenczi in the online journal of the Imágó Egyesület (Imágó Society of psychoanalysis in living society and culture) together with the former journal Thalassa (published since 1990). Concerning the more narrowly defined history of psychiatry, the psychiatrist Ferenc Pisztora needs to be singled out as the author of articles on a range of topics in nineteenth-century psychiatry (he is cited in the relevant chapters) together with the social psychologist Melinda Kovai for her more systematic work on the entanglements between psychology, psychiatry and politics during state socialism (1945–1970).15 As noted already, all of these authors, without exception, are with their primary background in psychology or psychiatry. Given the lack of comprehensive or even specialised reference works, this book is based on very extensive primary research. I draw on the abundant primary material of contemporary published sources of various kinds as well as unpublished material. These include: unpublished old asylum files, admission and discharge registers, statistics, original patient

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records and case histories, personal archival holdings of scientists, as well as published scientific journals, treatises and books, etc. A systematic review of one-half of a century production of the two main medical journals Orvosi Hetilap (Medical Weekly) and Gyógyászat (Medicine), together with the subsequently published Természettudományi Közlöny (Natural Scientific News), Egészség (Health), Klinikai Füzetek (Clinical Papers) and the documentation of the Royal Pest Society of Physicians as well as of the National Alienist Congresses give a sense of what priorities characterised mental health care, how these shifted over the period and how new professional concerns arose. Journal articles and comprehensive mental pathological textbooks demonstrate how the understanding of mental disorders changed due to professional, institutional and scientific factors, as well as how the doctor-patient relationship transformed during the observed period. The most valuable original source for this study consists of patient files containing almost 3,000 case histories between 1868 and 1915 in the Lipótmez˝ o Royal National Lunatic Asylum in Budapest and some others in the provinces. These files allowed an unprecedented systematic survey and the complex analysis of sociological and pathological parameters of the population of mental patients in major asylums in the Hungarian Kingdom over half a century: the reconstruction of the country’s hospitalised mental patient population in terms of nationality, religion, culture and language as well as socio-professional status throughout the entire observed period. Such an analysis is particularly fruitful in the light of Hungary’s unique conditions among contemporary European nation states due to her marked multi-ethnic and multi-denominational character. These archival sources also allowed the qualitative analysis of aspects of asylum life which are unrecoverable from published literature. ∗ ∗ ∗ Concerning the structure of the book, in Chapter 2, Psychiatric Histories and the Hungarian Model, I provide an overview of the history of care for the mentally ill in the Hungarian Kingdom in the period from the late-eighteenth century to the end of the First World War. The chapter captures a world without psychiatry prior to the establishment of the first viable private madhouse by Ferencz Schwartzer in 1850 and explores the available forms of care for the mentally ill, in particular the role of folk

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medicine and church relief, home cures and unorthodox healers. It examines attempts by the churches to monopolise care for the insane, early forms of state custodial care and the patterns of private provision for “the mad.” It then summarises the chief tendencies in psychiatric institutionalisation and knowledge production in the second part of the nineteenth century that form a framework for the specific institutions, psychiatrists and practices discussed in detail in the following chapters of the book. These main trends are placed in the context of various models of European psychiatric history offered by an abundant scholarship in the past decades. Crucially, the Hungarian model of psychiatric institutionalisation suggests idiosyncratic features concerning timing, periodisation and magnitude. Custodialism (the provision of custodial, rather than medical/therapeutic care in different institutions) marking the prehistory of psychiatry appeared on a small scale in Hungary until the middle of the nineteenth century, while the early custodial lunatic asylum phase characteristic in Western countries is clearly non-existent in the Hungarian Kingdom. The first viable mad house appeared at a time when the reform of the custodial asylum was largely over and the therapeutic asylum already had an almost one-half century history in Italy, France, England and some German states. This is not simply a delay, but rather a complete lack of a phase compared to general European trends of psychiatric institutionalisation. Despite initiatives by the centralised state, concerning the quality of care in a country with few healing institutions and little access to physicians, care for the insane was primarily the responsibility of the family and the local village or parish community until the middle of the nineteenth century (and even beyond). In addition, sources suggest that in Hungary, unlike in other national contexts, one cannot speak about a monopolisation of the care for the insane by the church either, and the private provision for the insane in mental institutions also did not become a significant pattern until 1900 and beyond. In the following three chapters, I study distinct types of institutions: the small private madhouse, the large public asylum and the university psychiatric clinic, together with their operational and therapeutic/research practices and underlying ideological discourse. I show how these separate institutions embodied distinct forms of life and cognitive universes. Marked by different conceptions of space and time, healing

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and other practices, and views of the psychiatrist’s function, these institutions framed different perceptions of mental illness and reflected different ideas of doctor-patient relationship. Chapter 3, The Bourgeois Family World of the Private Asylum. The Schwartzer Enterprise from 1850 explores the intellectual climate of early Hungarian psychiatry and the everyday world of Ferencz Schwartzer’s private lunatic asylum. Initiated at the time of political repression following the Hungarian war of independence in 1849, Schwartzer’s private psychiatric enterprise is placed in the context of the therapeutic asylum and moral treatment. His comprehensive theory of mental illness (presented in the first Hungarian book of its kind) demonstrates an expert knowledge informed by different medical, neurological and psychological traditions, including a form of humoral pathology embraced at the time in both Viennese and Pest16 medical circles, elements of Enlightenment dynamic-vitalism and neurology and of Romantic psychiatry. With an idiosyncratic combination of these traditions, Schwartzer came up with a remarkably holistic view of the human being complemented with a refined psychology and managed to conciliate the oppositions between organicist and psychic approaches as well as to claim special expertise within the medical community for the alienist trained in mental pathology. Everyday asylum life and the institute’s operational machinery are recaptured through arresting case studies of patients. The whole idea of the asylum as a therapeutic tool, together with moral (psychic) and physical treatment, was aimed at the systematic re-education and reorientation of the individual back to his or her family and society at large. Framed as a family, the madhouse community mirrored the family hierarchy so cherished by bourgeois society. The doctor posed as a patriarchal figure while the patient was seen as a child into whose life the doctor (re)introduced order and discipline. Mental illness was understood as a childlike state, and the doctor’s art consisted of a masterful control over the deluded childish psyche and the manipulation of fear. With most subsequent professionals trained by his textbook and in his private asylum, Schwartzer’s influence cannot be underestimated at the birth of Hungarian psychiatry. Chapter 4 entitled The Kingdom in Miniature. Public Asylums from the 1860s reconstructs the life and everyday practices and treatment in public asylums and discusses their legal, financial and managerial arrangements. Opened just a year after the 1867 Compromise between Hungary and Austria, the establishment of Lipótmez˝ o Royal National Lunatic Asylum in Buda was strongly connected to the recent constitutional triumph of

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the country and became a symbol of national independence and civilised statehood. In contrast to the private madhouse as a substitute bourgeois home and family for the deranged, the large public asylum functioned as a miniature version of the Hungarian Kingdom with its multiplicity of ethnic, religious, linguistic, social and cultural groups and traditions. In the outskirts of a hectic city, the large public asylum embodied traditional society and (political) order. It was a closed, self-contained and self-sustaining world. Its administrative machinery worked in the spirit of a modern state bureaucracy producing statistics, tables and charts in order to gauge the sociological and pathological parameters of the kingdom. With the advent of public state asylums in the 1860s, issues of the legal and financial arrangements of institutional mental health care came to the fore. Its complex system is recovered from original sources, giving rise to a picture of chaotic placement and movement of patients among institutions in the country. The chapter also reconstructs in detail the evolving legal regulations for patients’ admission, discharge and placement under guardianship. Contrasting these with the actual reality of these practices, one finds considerable discrepancies between regulation and implementation. Finally, the chapter captures aspects of the everyday life at the asylum, the conditions and problems with nursing, different forms of treatment (medication, work therapy, entertainments), the use of coercion, restraint and other types of disciplinary measures. Chapter 5, The University Clinic and the Birth of Biological Psychiatry. Academic Research, Teaching and Therapy from the 1880s, explores the rise of neuro-scientific research in Hungarian psychiatry from the 1870s and the establishment of the University Department in Mental Health and Pathology and its related clinic (1882). Compared to the microsociety of the asylum, the university psychiatric clinic was a very different “small world.” It functioned as an “obligatory passage point” for medical students, academic researchers, mental and nervous patients as well as criminals suspected of mental derangement (concerning the latter, most of these criminals were compulsorily brought in by the police for mental observation). Rather than provinciality, isolation, and closedness, characteristic of the asylums, the essence of the psychiatric clinic was progress, centrality, integration, and openness. Instead of representing order and an attempt to reproduce “normal life,” the small clinic was marked by chaos, a multiplicity of functions and the consequent fragmentation of the doctors’ work. Apart from its actual physical space, the psychiatric clinic also occupied a virtual space: it formed part of a boundless virtual

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network of scientists that extended beyond national borders. Beyond the physical space of the clinic/lab, the virtual space of this invisible college was the world of international journals and the transnational network of scholars. The chapter reconstructs distinct research practices (brain dissection, histological laboratory work, microscopic observation, experimental research) that became emblematic of the psychiatric clinic. For instance, I demonstrate that hypnosis was central to university psychiatry and clinical studies and that its investigation served clear professional and academic goals. Hypnosis research reveals professional anxieties over the “scientific” underpinnings of psychiatry in the period when the profession was still struggling to gain credibility and status among the medical disciplines. The controversies around hypnosis bring to light a deep schism within the psychiatric profession by the end of the century, a schism that can be explained by the crucial differences between forms of life, theories of mental illness and practices embodied in the institutions of the asylum and the psychiatric clinic, respectively. Many of the research practices at the psychiatric clinic showed an interest in the “dead” rather than the living patient, and in the case of living patients, the primacy of experimentation over treatment. Such experimentation reflected the sacrifice of the unity of the mind, soul and body of the person. Thus, in addition to professional power struggles, asylum doctors’ fierce attacks on laboratory research or experimental hypnosis research were also an attempt to rehabilitate the living patient and the holistic view that had traditionally characterised asylum psychiatry. Laboratory investigations in psychiatry, the concentration on brain anatomy and the patho-physiological and neurological mechanisms of psychiatric disorders at first gave rise to great hopes but in the end failed to advance therapeutics. New studies confirmed the organic nature of some mental diseases (such as the cause of paralysis in neurosyphilis) and claimed that many underlying pathological processes were irreversible. This was coupled with the disastrous conditions that were discovered to prevail in overcrowded asylums and hospital wards by the 1880s, as a result of which a general therapeutic pessimism pervaded psychiatry. This therapeutic “nihilism,” together with lacking resources, urged psychiatrists to look for alternative therapeutic solutions in other types of institutions and psychiatric practices. Chapter 6, Fragmenting Institutional Landscape. Alternatives of Specialised Institutions, Colonies and Family Care on the Turn of the Century demonstrates a move from

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“heterogenous” to “homogeneous,” specialised institutions based on the model of tuberculosis clinics and discusses in detail the lobbying for and establishment of institutes for epileptics, “imbeciles,” “idiot children,” criminals, nervous patients, alcoholics, etc. Creating “homogeneous” little islands of particular mental illnesses in the vast sea of mental and social pathology seemed at the time a more viable solution for psychiatric and social problems than the large institutions that functioned as a “melting pot” of mental disorders. Family care for the mentally ill was also strongly advocated alongside such alternative formations as colonies. These were spacious mental institutions consisting of many small houses rather than huge closed buildings and forming a mostly selfsustaining economic unit organised around some agricultural or other occupation, which also functioned as work therapy. Institutions such as the Dics˝ oszentmárton (1905) and the Nagydisznód (1906) colonies combined the characteristics of the colony with family care. After these chapters on institutions and their complex worlds of practices and theories, the following chapters demonstrate how the progressing disciplinary and institutional fragmentation of psychiatry went hand in hand with a gradual extension of psychiatric expertise into the public and private spheres of life by the end of the century. Psychiatry gradually moved beyond its narrowly defined disciplinary area and increasingly became a public affair. Formally investing mostly in the pathological realm of life and concerned with mental patients (individuals or institutional populations), psychiatrists extended their agency in the larger social domain and focused on more general social problems and their potential influence on healthy people, crowds and the nation. With these developments, they were gradually attributed expertise in the “hygiene of everyday life” as well as some control over the “health” of society. They touched politics and formed a social critique in ways unprecedented in psychiatric history. Chapter 7, Asylum Statistics and the Psycho-Social Reality of the Hungarian Kingdom explores the grounds on which psychiatrists could legitimately build and spread their social criticism. It demonstrates how asylums were scaled-down images of society by reconstructing the patient populations of three major mental asylums, relying on published statistics and the author’s original survey of asylum patient files. The latter enabled a systematic survey on almost 3,000 case histories between 1868 and 1915 and the complex analysis of sociological and pathological parameters of the mental patient population in the Kingdom, including those

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of gender, age at the time of admission, marital status, religious affiliation, social and professional status and mental illness diagnosis. The asylum population reflected the Kingdom’s social and cultural diversity and complexity, distorted in revealing ways by social, class and gender inequalities. Importantly, asylum statistics also suggest a strong correlation between grave social problems, such as alcoholism, prostitution, or pauperism, and dominant forms of mental pathology. The findings also allow for a critical reassessment of several claims prevalent in both late-nineteenth century psychiatric literature and the historiography of psychiatry. These include, among others, the argument that madness became a “female malady” in both cultural representation and institutional reality, the alleged “enormous” influence, widespread in nineteenth-century psychiatric texts, of female reproductive functions and biological processes on the mental state, and fin-de-siècle medical assumptions about Jewish nervousness. The analysis of the sociological and medical parameters of the inmate population also demonstrates that asylum files yield little evidence of the biological causes of or propensities for mental illness. At the same time, these data reveal the socially unequal “medicalisation” of society in this period, the different extent of access to and reliance on medical services by various social groups. Chapter 8, Invading the Public and the Private. The Hygiene of Everyday Life, Shell-Shock and the Politics of Turn-of-the-Century Psychiatric Expertise reconstructs the social criticism psychiatrist formulated in scientific forums and the public space, building on the strong connections, demonstrated in the previous chapter, between mental pathology and social problems. By intervening to solve these, including alcoholism, pauperism, prostitution, syphilis, effects of industrialisation, gender relations, political unrest, etc., psychiatrists contributed to the crystallisation of the hygiene of a healthy mental and physical “everyday” life, in which prophylactics figured centrally. The chapter situates their work within the wider context of “degenerationist” thinking, eugenics, and turnof-the-century culture. It discusses how manifestations of a perceived degeneration within “civilization”—capitalism, socialism, feminism, anarchism, the Decadent movement, crime, declining birth rates, high suicide rates and insanity—became signifiers of cultural crisis that contemporary scientists translated into a language of social pathology. The last section of the chapter reflects on shell-shock in Hungary, another area where psychiatrists’ political role was visible. It presents

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divergent theories on war neurosis and therapies and how this involvement with war neurosis helped psychiatry to further its social function through healing but also providing expert knowledge in areas of national concern: curing troubled soldiers and returning them to the battlefield as well as deciding who was a malingerer, a pension-seeker, etc. Shell-shock also allows us to discuss Sándor Ferenczi’s contribution to the matter and emphasise the short-lived, triumphant period of psychoanalysis with a centre in Budapest in 1918–1919. The final, concluding chapter summarises the complex developments in Hungarian psychiatry from the private asylum to a heterogeneous institutional landscape and from healing the mind of the insane to healing the ills of society. It recapitulates how—after the appearance of the first lunatic asylums and the clarification of the first concerns (treating mental patients isolated in asylums with professional care)—psychiatry went through growth and fragmentation that brought about multiple institutional forms, alternative therapeutic choices and psychiatric practices, and manifold professional roles in society. This multiplication and fragmentation, the crystallisation of distinct approaches and interests within the expanding professional community, went hand in hand with a growing sense of cohesion of the psychiatric profession at large. It resulted in the extension of psychiatric expertise to social areas and the appropriation of cultural monopoly over a number of issues related to the hygiene of everyday life as well as a “healthy” society.

Notes 1. See Ernest Gellner, Language and Solitude: Wittgenstein, Malinowski, and the Habsburg Dilemma (Cambridge: Cambridge University Press, 1998). 2. From the Compromise in 1867 till its dissolution in 1918, the Austro-Hungarian Monarchy (or Dual Monarchy) comprised both Austria and the Hungarian Kingdom as two parts of the dualist state. It is also often referred to as the Habsburg Monarchy or the Habsburg Empire. 3. Carl E. Schorske, Fin-de-Siècle Vienna: Politics and Culture (Vintage Books, 1979). 4. Péter Hanák, The Garden and the Workshop (Princeton University Press, 1998).

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5. I widely refer to western historiography in the relevant chapters throughout the book and give a more systematic review of the scholarship in Chapter 2 which outlines Western psychiatric developments. 6. See illustrated in detail at the beginning of Chapter 2. 7. For a review of the origins and characteristics of the fields of medical history and science in East-Central Europe, see Tatjana Buklijas and Emese Lafferton, eds., “Science, Medicine and Nationalism in the Habsburg Empire from the 1840s to 1918,” Studies in History and Philosophy of Biological and Biomedical Sciences 38 (2007): 679–774. 8. Magyar Orvostörténelmi Társaság, founded in 1905, re-founded in 1966, http://mot.orvostortenelem.hu/. 9. http://semmelweismuseum.hu/. 10. Pál Harmat, Freud, Ferenczi és a magyarországi pszichoanalízis. A budapesti mélylélektani iskola története, 1908–1983 (Bern: Európai Protestáns Magyar Szabadegyetem, 1986), with a second, revised and enlarged edition that came out at Sopron: Bethlen Gábor Könyvkiadó, 1994. 11. See Ferenc Er˝ os, ed., Ferenczi Sándor (Budapest: Új Mandátum, 2000); Ferenc Er˝ os, Kultuszok a pszichoanalízis történetében (Cults in the History of Psychoanalysis) (Budapest: Jószöveg M˝ uhely, 2004); Trauma és történelem: Szociálpszichológiai és pszichoanalitikus tanulmányok (Trauma and History: Studies in Social Psychology and Psychoanalysis) (Budapest: Jószöveg M˝ uhely, 2007); Pszichoanalízis és kulturális emlékezet (Psychoanalysis and Cultural Memory) (Jószöveg M˝ uhely, Bp., 2010); Psziché és hatalom. Tanulmányok, esszék (Psyche and Power. Studies, Essays) (Budapest: Pesti Kalligram, 2016). 12. See Csaba Pléh, A lélektan története. 2., b˝ ovített kiadás (The History of Psychology, 2nd, extended edition) (Budapest: Osiris Kiadó, 2010); History and Theories of Mind (Budapest: Akadémiai Kiadó, 2008); A pszichológia örök témái. Történeti bevezetés a pszichológiába (Major Themes in Psychology. Historical Introduction to Psychology) (Budapest: Typotex, 2008). 13. Judit Mészáros, “Az Önök bizottsága” —Ferenczi Sándor, a budapesti iskola és a pszichoanalitikus emigráció (Budapest: Akadémiai Kiadó, 2008) and Judit Mészáros, ed., In memoriam Ferenczi Sándor (Budapest: Jószöveg M˝ uhely, 2000).

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14. See her work on the connection of psychoanalysis and spiritualism in Hungary in her short monograph: A szellemekt˝ol a tudattalanig —Tudomány, áltudomány, pszichoanalízis (Budapest: L’Harmattan, 2019). 15. Melinda Kovai, Lélektan és politika—Pszichotudományok a magyarországi államszocializmusban 1945–1970 (Psychology and Politics. Psy-Sciences During Hungarian State Socialism 1945–1970) (Budapest: L’Harmattan, 2016). 16. The territories of Buda, Pest and Ancient Buda were only united in 1873 to form a single city: Budapest.

CHAPTER 2

Histories of Psychiatry and the Hungarian Model

The Self-Image of Late-Nineteenth-Century Psychiatry Born at the end of the last century, psychiatry slowly gained strength and cast the different philosophical and ethicoreligious doctrines out; organised itself on the firm foundations of the natural sciences, and showed a new direction in therapeutics which began in the 1830s with the elimination of the coercive tools and resulted in a number of new, monumental institutions furnished comfortably and with all the scientific equipments which brought about the unforeseen development of psychiatry.1

In the minds of nineteenth-century psychiatrists, the story of their discipline was intertwined with ideas of civilisational progress and national pride. This history consisted of acts of “separations” or “detachments” and subsequent building. Psychiatry first had to gain distance from the church, philosophy, and, in a way, medicine (other medical sciences) as well to free itself from undesirable constraints. The purpose of these detachments or separations was to define the field and heritage of psychiatry and to delineate it as markedly distinct from what we could call the prehistory of dealing with madness. The argumentation of the above quotation manifests a belief in an unbroken path of development, a familiar element in late-nineteenth-century psychiatrists’ accounts; it © The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 E. Lafferton, Hungarian Psychiatry, Society and Politics in the Long Nineteenth Century, Mental Health in Historical Perspective, https://doi.org/10.1007/978-3-030-85706-6_2

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builds on the evolutionary logic that values modern scientific thinking over the superstitious past. The story was about “a society standing on a low level of civilisation and living in blind faith and ignorance” that read the mental patient’s “striking behaviour and confused talk, hallucinations and illusions, not as signs of disease,” but as proof that the person “incurred God’s damnation and now the devil reigns over him.” Pointing to the enormous influence of the church on the unenlightened mind, the asylum psychiatrist László Epstein, for instance, repeats the beliefs shared by many of his colleagues that “numerous melancholics, hysterical, epileptic and other mental patients ended their lives burning at the stake.”2 Interpretations and inquiries into strange human behaviour as well as into the realm of the mind had to be expropriated not only from the church but also from philosophy. The new psychiatric discipline had to be based on natural scientific foundations and cultivated not by philosophers but trained doctors. “Even at the end of the eighteenth century, the great Ideler3 thought that mental afflictions were merely wild and unmanageable passions, and, influenced by the philosophy of Kant and Schelling, it was still highly debated whether the philosopher or the doctor was qualified to make judgements concerning pathological psychic states,” argued Ern˝ o Moravcsik, eminent clinical psychiatrist in 1906.4 The relationship with medicine was seen as more problematic. Here not so much a detachment, rather a differentiation or distinction was needed, the establishment of distinct disciplinary boundaries between the different medical sciences. Here psychiatry had to consider that, in certain respects, it did not live up to some core criteria of medicine while it still had to prove its medical scientific status. Psychiatry was handicapped as a science. For a long time, it was considered too “subjective,” its symptomatology could hardly be based on anatomy, its core concepts were borrowed from philosophy (…), and objective means of measurement were out of the question. But, as widely held in these optimistic reports, institutionalisation finally established the “scientific foundation and further development of psychiatry” within well-equipped university clinics and thus psychiatry “gained citizenship rights among the medical sciences.”5 Apart from serving broader civilisational goals, the establishment of psychiatry in the Hungarian Kingdom was also a fundamentally nationalist project, a part of the building of the nation state. The emerging psychiatry’s self-image did not only incorporate ideas of scientific progress and

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social development, it also became the embodiment of national history and a “national cause.” Psychiatry’s past, present and future were seen as intimately intertwined with the country’s painful struggles in her past, her present condition and future prospects of becoming a civilised European nation. The idea of psychiatry as a pledge for cultural excellence and civilised nationhood is elaborated for instance in Ern˝ o Moravcsik’s reasoning. According to his narrative, in the first part of the nineteenth century, Hungarian psychiatry was in its “infancy,” there was no independent research in the field. Some form of mental health care had to be established, which was impeded by several factors: political crises, priorities of the programme of national awakening, the need for the rearrangement of the state and its constitutional set up—all of which constituted enormous financial burden for the country. “There were many tasks into numerous directions that had to be achieved in order to elevate our country to the level of civilised nations in a short period of time.”6 Opened soon after the 1867 Austro-Hungarian Compromise, Lipótmez˝ o National Asylum7 became attached in the minds of many with the history and fate of the country. Perhaps paradoxically, it came to embody independent nationhood. Although planned and built during the neo-absolutist period, it was nevertheless interpreted as a great achievement of the constitutional era.8 In the memories of Gusztáv Oláh, a late-nineteenth-century asylum doctor, contemporary Pest and Buda were proud that the “first great achievement of independent statehood” was an “unproductive institution standing for civilisation.”9 Oláh wondered if it was national vanity that explained such a luxurious building and he likened it to the architecture of the London asylum Bethlem, which in the seventeenth century was rebuilt in the semblance of a royal palace: a national fortress modelled on the Tuileries in Paris and embodying national rivalry. “Lipótmez˝ o was also built with the extravagance and … wastefulness of a princely castle,” Oláh o in Hazánk ironically added.10 The author of a 1867 article on Lipótmez˝ s a Külföld (Our Nation and Foreign Countries) also describes it as a “national edifice … of enormous extension,” “one of the most grandiose buildings of our nation,” which towers above the beautiful park “with striking beauty, as a stupendous palace.” Its facade is “decorated with a colossal national coat of arms and crown artistically carved from a huge stone.”11 The coat of arms on the façade in fact was originally planned with the Habsburg two-headed eagle but was in the end switched for the

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Hungarian crown (as if “it were the seat of the country’s highest political authority”12 ). The national lunatic asylum itself became a national symbol. The only thing that many could consider a flaw, according to Oláh, was the German name of the institution’s first director, Emil Schnirch, who was “nonetheless of Hungarian origin and feeling.” Oláh’s anecdotal story of Schnirch’s first visit to Béla Wenckheim, the Minister of Interior, is telling about the national sentiment and meaning attached to the asylum. When Schnirch introduced himself, Wenckheim allegedly replied that such a German-sounding name was not so fortunate at the head of the country’s greatest institution and advised Schnirch to “magyarize” it. Schnirch’s bold and self-conscious response was that “In this question, I will regard your Excellency as an example to be followed!”,13 which Oláh explained with Schnirch’s intoxication with his new prestigious position. Mental health care became the “measure of a country’s state of civilisation”: “the more developed a country’s culture was,” “the more numerous are the arrangements with which state and society together attempt to take care of its mental patients.” In this respect, as Epstein proudly concludes, “our nation has not only displayed a sense for culture, but also gave proof of its ability to develop culture from its own resources.”14 This enthusiastic and rather optimistic picture of the emergence of Hungarian psychiatry, of course, tells more about how psychiatrists saw themselves than about anything else. Their claims are, however, pertinent to the story of the emergence of psychiatry, as they reflect a proud nationalist concern connecting the development of psychiatry with the formation and modernisation of the nation state. At the same time, they also testify to the historical process during which early practitioners had to compete with myriads of traditions and self-appointed specialists in interpreting and treating madness. Bodies of knowledge, roles and practices had to be appropriated by an emerging group of professionals from philosophers who speculated about the relationship of the mind, the soul and the body, from the general medical community that produced rival frameworks for explaining madness, from clergymen who traditionally administered to matters of the soul, and from individuals of various standing, eager to alleviate the sufferings of the insane with alternative practices (“quacks,” wise women, holy men, herbalists, etc.). All of these were crucial in the formation of a profession that could eventually claim

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expertise and exclusive right to interpreting and tending to the mind and the psyche. In order to reach a more realistic and historically reliable narrative about the emergence of Hungarian psychiatry than the one offered in the self-image of psychiatrists in the period, this chapter draws the map of various historical contexts for the process. First, I briefly outline some main trends in the prehistory and early phase of psychiatry in different European countries based on the scholarship produced in the field of psychiatric history during the last decades. Then an outline of Hungarian psychiatric history is presented with reference to the main institutions, psychiatrists and practices that will be more amply discussed in the rest of the book. In the present chapter, I lay more emphasis on a number of closely related issues that are not dwelt upon later in the book but might be useful as a background for the reader uninitiated in Hungarian medical history (such as the organisation of public health care, the availability of healing institutions, the development of medical teaching, to name a few).

Histories of European Psychiatry The World Without Psychiatry According to general histories of madness in Europe,15 insanity was primarily a family responsibility and burden from the ancient Greeks through the late eighteenth century. Christian Europe made first of all the family and the close community of the parish responsible in the matter, though institutionalised isolation of the insane began in the late Middle Ages. This was mostly upon religious initiatives motivated by piety, like the madhouse of St Mary of Bethlehem in London from the late fourteenth century, the healing centre in the Flemish village of Geel , and early asylums in fifteenth-century Spain.16 These, however, did not result in the large-scale management of the mad. In his influential book, A History of Psychiatry, Edward Shorter depicts a rather gloomy picture of a “world without psychiatry” revealing a general hostility, lack of understanding, and the widespread use of physical brutality against the insane in pre-modern Western societies. “In a world without psychiatry, rather than being tolerated or indulged, the mentally ill were treated with a savage lack of feeling. Before the advent of the therapeutic asylum, there was no golden era, no idyllic refuge for those supposedly deviant from the values of capitalism. To maintain otherwise is a fantasy.”17 While

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numerous sources indeed reflect animosity, lack of understanding and physical brutality towards the mad in pre-modern times, Shorter’s view of early family care can partly be seen as the result of his somewhat distorted view of the history of psychiatry18 and partly as a criticism of Michel Foucault’s interpretation of the period preceding the time of the “great confinement.” In his highly influential early study, Madness and Civilisation (originally published under the title Histoire de la folie in 1961), Michel Foucault proposes a powerful theory in discussing the historical roots of psychiatry. In his chapter, “The great confinement,” Foucault studies the mushrooming of “enormous houses of confinement” throughout Europe from the seventeenth century: the wards of the Hôpital Général in Paris, cells of prisons, bridewells and workhouses where the poor, the prisoners, the vagabonds, the insane and the unemployed were incarcerated. Foucault is interested in the “judicial conscience that could inspire” the practice of confinement as well as the “meaning of this proximity” which provided the rationale for the aggregation of precisely these groups of people in distinct institutions that were not assigned medical functions.19 In Foucault’s interpretation, confinement was both a moral imperative and an economic tactic,20 as its original function (to aggregate people) was complemented with a new function: to make those confined work and thus contribute to social prosperity. Confinement was a matter of policing that understood work as a necessity: its rationale was organised around bourgeois values of the “imperative of labour,” a “condemnation of idleness.” The historically new element in confinement from the mid-seventeenth century was that the deviant and workless person was no longer simply punished or exiled, but, according to an “implicit system of obligation,” the madman was taken into custody at public expense and deprived of his individual liberty (48). The new institutions of confinement did not simply operate as a refuge, not even merely as a “forced labour camp,” but they had an “ethical status” as a “moral institution responsible for punishing, for correcting a certain moral ‘abeyance’ which does not merit the tribunal of men, but cannot be corrected by the severity of penance alone.” In the new era, the madman no longer lived in the world of the irrational. He “crosses the frontiers of bourgeois order of his own accord and alienates himself outside the sacred limits of its ethic.” The “old rites of excommunication were revived, but in the world of production and commerce,” and its ethical basis was derived “from the law of work” (57–60).

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Foucault’s interpretation built on a complicity theory involving the Monarchy and the bourgeoisie and saw confinement as integral part of the secular (monarchical and bourgeois) order in France. While he states that the church was left out of the organisation of the Hôpital Général, the house of confinement in the classical age “constitutes the densest symbol of that ‘police’ which conceived of itself as the civil equivalent of religion for the edification of a perfect city” (63). The institutions of absolute monarchy that became symbolic of its arbitrary power thus bear the inscription of “the great bourgeois, and soon republican, idea that virtue, too, is an affair of state, that decrees can be published to make it flourish, that an authority can be established to make sure it is respected” (60–61). Foucault’s Madness and Civilization represents a powerful trend of anti-psychiatry from the early 1960s. This trend was also marked by works such as Thomas Szász’s The Myth of Mental Illness, Erving Goffman’s Asylums and R.D. Laing’s The Divided Self .21 The Hungarian-born Thomas Szász was undoubtedly the most influential spokesman for the interpretation of psychiatry as a professional plot, a conspiratorial scheme by its practitioners in the “manufacture of madness.” With his elaboration of the notion of mental illness as a “myth,”22 Szász went as far as denying the autonomous existence of insanity as a disease.23 While this scholarship electrified the field and provoked a wealth of literature with its critical intent of uncovering the sinister aspects of and conspiratorial forces behind psychiatric institutionalisation, its ideological and political content is indubitable. Intellectually, this literature was a critical response to the Whiggish historiography of psychiatry in the 1930s–1950s, marked by internalist and progressivist accounts with special emphasis on the “great representatives” of psychiatry and a cumulative, optimistic intellectual history largely neglecting the wider social context of its working. Politically and ideologically, it was a fierce attack on the institutional structures of power in modern society and a radical movement against contemporary psychiatric institutions, embedded in the counter-cultural movement of the 1960s.24 While anti-psychiatry was a revisionism of Whiggish psychiatric history of the former decades, it also provoked a new revisionism of its own ideological and intellectual tenets.25 Although many studies followed in the Foucauldian and antipsychiatric line in the 1970s (some of these produced by sociologists and social historians),26 Foucault’s explanation of European psychiatry’s

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historical roots (or prehistory) in the state-led sequestration of lunatics together with vagabonds, petty criminals, prostitutes, etc., taken as a form of policing by the absolutist state and widely applicable to Europe has been contested by many scholars.27 Thanks to the growing field of psychiatric history from the 1980s, numerous scholars have studied the distinct national psychiatric histories of different European nations and scrutinised new aspects of the field.28 Roy Porter provided a convincing criticism of Foucault’s ambitious thesis in his Mind-Forg’d Manacles, by now regarded as a classic history of madness in England in the period from the Restoration to the Regency.29 Porter only partially accepted the model provided by Foucault. While he believed that a pessimistic interpretation of the emergent policy targeting the socially dangerous and difficult as an essentially repressive scheme sounded more realistic than Whiggish historical accounts of the Age of Reason freeing the mad, Porter listed several observations that undermined Foucault’s theory. He saw a problem with the assumed magnitude of confinement which “was hardly ‘great’”30 and claimed that there was neither central nor local co-ordination for sequestering the poor insane in England during the eighteenth century.31 At the end of the eighteenth century, England had eight asylums or public charities (the most famous of which was the London city-run Bethlem which catered to only 122 patients in 1815), whereas a greater number of the insane were taken care of in private asylums.32 The number of licensed private asylums totalled around 50 in 1800.33 According to Shorter, by 1826, “not quite five thousand insane people were confined in any form, 64% of them in the private sector, 36% in the public … in a country of 10 million people.”34 Porter also disagreed with the interpretation that, due to the underlying bourgeois work ethos, lunatics were “set to work as a moral duty.” Asylum life itself was characterised by idleness, and when introduced, work was employed as therapy rather than punishment.35 As Porter claims, in the rest of Europe, state-organised institutionalisation emerged considerably later (the great confinement was brought about in the nineteenth century); whereas in urban Europe, and especially in England, the rise of the asylum was mostly an offshoot of commercial society, initially devoid of medical attendance.36 The intensive “trade in lunacy” (as Parry-Jones called it), the profit-oriented and unregulated free market in the control of madness emerging in eighteenth-century England was characterised by numerous private asylums often led by lay

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superintendents and without any medical supervision.37 These institutions inspired by the entrepreneurial spirit carried primarily custodial and not therapeutic functions. The use of physical coercion was widespread with some form of order attained by the brutal use of chains and whips. These practices and attitude later qualified as inhumane and unacceptably cruel, however, were pervasive givens in European societies at the time.38 Foucault’s theory is by now generally accepted to be pertinent only to the French situation, though in Shorter’s mind, not even to that.39 According to him, in more centralised France, late-eighteenthcentury public custodial institutions (including the hospices described by Foucault), with the paradigmatic examples of Bicêtre and Salpêtrière hospitals, were places of internment for all kinds of poor, old and deviant people. However, these institutions were not therapeutic institutions and the number of psychiatric patients hosted within their walls was not considerable.40 Shorter stresses that little data is known yet concerning the “the exact mix of inmates” in workhouses and hospices, “but the number of beggars, elderly people, and organically ill in these institutions seems to have been so high as to give them a decidedly nonpsychiatric stamp.”41 In the smaller states of Central Europe, lacking the centralised government of France, the responsibility for psychiatric care was divided between state, church and local community. Some of the German Tollhäuser (fools’ houses) date back to the Middle Ages, while the eighteenth century produced new asylums, almshouses and jails. However, there is no evidence of any great confinement, Shorter states. In statist Germany, “psychiatry was a dead letter before the nineteenth century.”42 Austria, under more centralised rule, did not produce numerous lunatic asylums until quite late. In Vienna, the first madhouse, Narrenturm (“fools’ tower”), was established by Joseph II in 1784 (together with the 2,000bed Allgemeine Krankenhaus ) as a sign of the enlightened absolutist drive for centralisation. The round-shaped building contained 139 barred cells on five floors with corridors running inside and opening to the court. With its heavy bars and chains, the Narrenturm was a place of gothic horror, true to the concept of health police by aiming at protecting the insane from themselves and society from the insane.43 In Prague, a Tollhaus was built attached to the public hospital in 1790.44 Plans for new buildings to provide more adequate care for the insane in the Austrian capital were postponed from time to time. The famous Döbling madhouse

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built in the outskirts of Vienna in 1819 was, according to Erna Lesky, the first private hospital specialising in the insane in Austria.45 We can conclude that early custodial institutionalisation neither reached great magnitude, nor was characterised by therapeutic intent. These institutions neither helped to mark the dividing line between the mentally ill and other poor inmates, nor used practices that would later be introduced in psychiatric institutions. Therapeutic Asylums and Moral Treatment A significant change in the care of the mad occurred when new ideas emerged stressing the advantage of the isolation of the insane in asylums where management of the patients became more important than traditional medical administration to the body. The belief that the isolated world of the asylum was beneficial for the patient was espoused with the Enlightenment notion of curability and a new therapeutic optimism pervading the medical world in the second part of the eighteenth century. The cruelty, neglect and physical coercion that characterised early custodial institutions and asylums were largely exchanged for more humane and often even affectionate treatment. Former forms of mechanical restraint (the chains, cuffs and whips) were discarded and the only “legitimate” tool to control patients that remained was the straitjacket. By the nineteenth century, the “new” or “therapeutic” asylum was heralded as a progressive institution, in fact the only institution that could provide effective treatment for the mad. While this movement was international and general scholarship names the Italian Vincenzio Chiarugi (1759–1820), the French Philippe Pinel (1745–1826) and members of the English Tuke dynasty as the main heroes of this reform movement, Shorter pinpoints the emergence of the idea of the therapeutic asylum in the work of the English William Battie, founding medical officer of St. Luke’s Hospital in London.46 Chiarugi, physician in an overcrowded hospice in Florence, lobbied for the renovation of the old Bonifazio hospital which opened in 1788 as a new mental hospital. Chiarugi had a clear idea of how to regulate and run it with the intent of curing the patients isolated within its walls. He attempted to minimise restraint and substitute cruelty with kindness and humane treatment.47 The hero of the therapeutic asylum, however, was undoubtedly Pinel whose significance in the history of psychiatry was further enhanced with stories about his freeing the insane from

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their chains at Bicêtre in 1794.48 In 1795, Pinel became the director of Salpêtrière. Based on his experience at these institutions, his work Traité médico-philosophique sur l’aliénation mentale (Paris, 1801) became the manifesto of reformed therapeutics for the insane in the upcoming decades. For Pinel, insanity was primarily a mental condition. He stressed the psychological factors in the aetiology of insanity and emphasised psychological treatment, the almost exclusive use of le traitement moral and the abandonment of medical treatment49 (although he used the latter in cases where moral therapy failed).50 Moral therapy consisted of gentleness and the exploitation of the doctor’s face-to-face authority and charismatic powers. In line with Enlightenment thinking, the insane patient was no longer seen as an animal, but as a human being whose deluded ideas could be corrected with the power of rationality and the introduction of order.51 Ordered life, work and systematic activity thus became the essential tools of therapy, complemented with the use of warm baths to calm patients. Pinel’s pupil, Jean-Etienne-Dominique Esquirol (1772–1840), put into practice Pinel’s idea of the therapeutic community and was the most important follower of moral therapy in Paris in the following decades.52 The origin of moral treatment in England53 (which developed independently) is traditionally traced back to the work of William Tuke in his York Retreat, a private asylum he founded in 1796.54 A Quaker tea-merchant, Tuke, set up his private retreat to provide therapeutic care for the Quaker community after a scandalous incident at the old York Asylum which outraged the community and was detrimental to the asylum’s reputation. The Retreat was run by the merchant dynasty for several generations. At the York Retreat, patients and staff formed a closed community, they lived, worked and ate together. The management of asylum life became regarded as therapeutic, bolstered by a system of praise and punishment which aimed at the re-education of the person through the restoration of self-control.55 An increasing emphasis was laid on the internalisation of self-discipline and bourgeois values of work, time and order which followed the line of the long-term process of civilisation described by Norbert Elias in his influential work The Civilising Process. Due to the efficacy of the York Retreat in treating the mad, moral therapy spread in England and was practised in numerous asylums in the first part of the nineteenth century.

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Moral treatment came to mark enlightened asylum administration and was justified by claims of humanity and efficacy. It cherished the interpretation of insanity as a disease and emphasised the need for care within asylums and hospitals rather than in jails and workhouses. The practice of the therapeutic asylum, however, raised a crucial question regarding the role of doctors in the treatment of the insane and threatened the status and very existence of physicians within asylums. If asylums needed a sensitive staff, careful tending and common sense in their interaction with patients, with a refusal of medical therapies, then medical theories of insanity, traditional therapeutic regimens as well as the establishment of the position of medical men in the care for the insane, were all threatened. All of this produced a kind of defensiveness in the psychiatric literature of the 1810s and 1820s. In Bynum’s words, “the rise of moral therapy was not an unmixed blessing,” for the doctors at least.56 In 1815 and 1816, inspections by the Parliamentary Committee of Madhouses reported on the success of the York Retreat while uncovering serious mismanagement and the wide use of physical abuse in the London Bethlem or at the York Asylum (which was run by a physician). The York Retreat was founded and run by laymen, with the Tukes sharing a strong antipathy for medicine. Samuel Tuke’s (the grandson of William Tuke) Description of the Retreat, an Institution Near York for Insane Persons of the Society of Friends (1813) contained a serious criticism of doctors’ capacity to deal with insanity.57 However, Bynum claims that, among the three rivalling positions concerning the nature of insanity in British psychiatric literature in the late eighteenth and early nineteenth centuries, the majority of the physicians believed that insanity was essentially a physical condition accompanied by structural changes (the other two positions being: insanity as always a mental condition; insanity being the result of either physical disease or mental aberration).58 Although this belief in the physical nature of insanity was not supported by much evidence and although many of the physicians showed admiration for and in fact practised moral therapy, only a few were willing to entirely give up the medical treatment of mental patients.59 In a way, phrenology was a life preserver for physicians. Formulated by Joseph Gall (1758–1828) in the decade he worked in Vienna from 1795 to 1804, phrenology was the science of brain anatomy, physiology and localised pathology. As a medical practitioner in Vienna, Gall was allowed to observe mental patients in the Narrenturm . First as a cranioscopist

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then as a brain researcher, Gall maintained that the skull was a faithful reproduction of the underlying brain surface and attempted to localise intellectual and moral qualities (believing that these were the functions of the brain) in the cerebral cortex. Gall’s research is today regarded as the precursor to modern brain localisation.60 Although dismissed in early psychiatric historiography as pseudoscience, the role of phrenology “completely reoriented psychiatry,” Roger Cooter claimed.61 Phrenology supplied ammunition to moral therapy with its scientific and somatic underpinnings. By relating psychological factors to brain functions, phrenology offered a rational scientific framework based on organicism in which “moral treatment became a logical and comprehensible system of exact causal relationships between physical and psychological factors.”62 Highly influential in the decades between the 1820s and 1840s in England (and elsewhere), phrenology helped physicians partly regain their status that had been damaged by the introduction of moral therapy.63 In spite of these developments elsewhere in Europe, a more humane treatment of the mad began considerably later in Austria. Bruno Goergen (1777–1842), primarius at Narrenturm between 1806 and 1814, set up the first private madhouse in Austria in 1819 where he introduced moral treatment and refrained from using coercive tools. The thriving Döbling asylum became even more successful in the second part of the nineteenth century (under the management of Max Leidesdorf and later Heinrich Obersteiner)64 and housed, among others, Count István Széchenyi, the influential Hungarian politician who became deranged during the 1848 Revolution. Reform, however, reached Narrenturm only in 1839 when the Hungarian-born Mihály Viszanik (1792–1873), who taught mental pathology at the Vienna Medical Faculty, became primarius at the institution. Viszanik discarded many of the chains, though not all mechanical restraints,65 at the time when in England John Conolly already introduced the no-restraint system in the public asylum in Hanwell near London.66 Viszanik was active in reforming mental health care in Austria.67 He made a research tour to French, German and Swiss mental institutions in 1843, and partly due to his endeavours, the Imperial Royal Institution for the Treatment and Care of the Insane was opened in Bründlfeld (Vienna) in 1853. Designed for 700 patients with space for occupational therapy and surrounded by large parks, the institute lived up to the psychiatric standards of the time. Under the directorship of Joseph Gottfried

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Riedl between 1851 and 1869, the no-restraint system was introduced to Vienna.68 Mental institution building speeded up in the second part of the nineteenth century in Austria. Just during the years between 1898 and 1914, seven mental institutions were built from scratch in Cisleithania (Austrian half of the Habsburg Empire): two in the Crown Land of Lower Austria (Mauer-Öhling and Am Steinhof ), one each in Bohemia, Moravia, Galicia, Trieste and Gorizia. The smallest of these was the asylum in Gorizia opened with 350 beds and 21 separate buildings, the largest, Am Steinhof in Vienna with 2,200 beds and 60 buildings.69 The nineteenth century saw the mushrooming of lunatic asylums in most Western European countries, in spite of the different national traditions of health care provision.70 Compared to England, where voluntarism and charity initiatives prevailed rather than state intervention and where the management of health care for the poor was left to the local community, in highly centralised France public health care was controlled from Paris and state legislation defined health care regulations from above.71 Austria, the German states and Switzerland showed a strong “health paternalism”72 as these countries were characterised by the central direction of health care and medical matters embodied in the notion of “medical police.”73 The German model of centralisation was affirmed with the foundation of the Empire (1871), since earlier distinct administrative models were applied in the different states. State medicine developed in France at the general hospitals from the seventeenth century, in Austria at the Viennese Medical Faculty from the middle of the eighteenth century and in Germany at medical faculties of the separate state universities (some 20 altogether).74 In most countries, however, the asylums established with great hopes proved to be insufficient by the last decades of the nineteenth century.75 It is generally argued in the historiography of European psychiatry that the number of the mentally disordered in psychiatric institutions went through an incredible increase during the nineteenth century. The end of the therapeutic asylum era in Western Europe was brought about by the “pressure of numbers,” that is, the constant flux of mental patients to institutions that doomed the therapeutic asylum to failure: overcrowded by numerous hopeless cases (paralytics, alcoholics and those suffering from paranoia, etc.), with high death-rate and little time available for individual patients, these institutions were unable to live up to their therapeutic ambitions.76

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Academic Research and Biological Psychiatry With its roots in the Renaissance and the Enlightenment, public science flourished in the nineteenth century due to scholarly activities in universities and research centres developed and funded by states. Medical science first gathered momentum in France where new ways of investigation were introduced. Clinical medicine based on strict protocols of observation developed in French hospitals since the first decades of the nineteenth century: the physical examination aimed at identifying the objective signs of disease (pathological phenomena the doctor finds in a patient)—as opposed to the subjective symptoms —gave rise to new disease concepts. Observation of the living patient was complemented with meticulous search for lesions on the dead body. New instruments, like the stethoscope, were used in physical examination which allowed “peeking” into the living body of the patient and identifying pathological inner changes in the organs.77 The influence of new French medicine reached everywhere in Western Europe and as a result, the rich clinical material of hospitals brought medical investigation to the fore, while medical teaching also grew hospital-based.78 Meticulous patient observation had a long tradition in Austria as well. During the time of the “First Vienna School” from the middle of the eighteenth century, the Dutch chief physician of the Habsburg Empire, Gerard van Swieten, introduced reforms aimed at the establishment of bedside medicine and teaching, which were based on ideas of the Leiden University professor Hermann Boerhaae. The strongly conservative turn from the last decade of the eighteenth century, however, threw Viennese medicine back for decades until new developments in medicine in the 1840s gave rise to the “Second Vienna School.”79 Besides hospital medicine, a competing institution and related practices were strengthened by 1850: the laboratory and experimental research. Relying on the technological advancement in microscopy and espousing scientific materialism, systematically controlled experimentation came to the fore in numerous medicine-related disciplines, especially in physiology and chemistry, and flourished in research faculties where scholarly findings were immediately echoed in medical education. In this field, German universities became the leader.80 French medicine lost its former status since it failed to create laboratories and thus develop a researchbased experimental medical culture matching that of Germany. In midnineteenth-century Britain, medicine was still mostly practised by private

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physicians and university research was poorly subsidised. Vienna, however, revitalised after three decades of medical conservatism at the beginning of the nineteenth century, could regain its leading role as a supreme medical centre in Europe due to the work of a handful of professors around the Bohemia-Moravian-born Carl von Rokitansky (1804–1878).81 German dominance in academic (or biological) psychiatry of the era was due to numerous state-supported universities and asylums, such as the famous Illenau in Baden-Baden,82 where clinical experience was gained by psychiatrists, but German psychiatry was also progressive in its researchoriented medicine. Lecturing in psychiatry began by Johann Heinroth83 (1773–1843) in Leipzig in 1811 and was followed by a few sporadic initiatives. These were, however, short-lived and did not attain later standards of combining departmental lecturing with practical demonstration at a psychiatric hospital or clinic attached to the Medical Faculty. This ideal became realised by the eminent Wilhelm Griesinger (1817– 1868) in Berlin in 1865 and subsequently became the overriding pattern in the Germanic world.84 Griesinger’s famous dictum that mental disease was a disease of the brain and insanity was thus only a symptom lead to research agendas scrutinising the underlying anatomical cause of psychiatric illnesses. The most eminent representatives of this trend in the Germanic world were, among others, Griesinger’s successor in Berlin, Carl Westphal (1833–1890), the Dresden-born neuropathologist Theodor Meynert who energised neuroanatomical investigations in Vienna from the late-1860s, and Carl Wernicke (1848–1905) focusing on problems of cerebral localisation.85 While laboratory investigation brought about the development of new biomedical sciences, therapeutics was lagging behind. In spite of great hopes concerning parallel improvements in cure, the concentration on brain anatomy and the patho-physiological and neurological mechanisms of psychiatric disorders eventually failed to advance therapeutics. Such research substantiated the organic basis of some mental diseases as well as their gloomy outcome, like the cause of paralysis progressive caused by neurosyphilis. Disastrous conditions at overcrowded asylums and hospital wards elicited much professional criticism and public concern, all of which gave rise to a general therapeutic pessimism or “nihilism” in psychiatry.86 The population of these institutions revealed strong connections with social problems that directly influenced psychiatric illnesses: the rise of the number of paralytics, alcoholics and neurasthenic patients made social factors become ever more relevant in psychiatric thinking and

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produced numerous psychiatric works that contained strong social criticism targeting alcoholism, prostitution, pauperism and the consequences of capitalism and modernity. These social factors and elements of organicism combined in the all-pervasive theory of degeneration first systematically described by French psychiatrists J. Moreau de Tours (1804–1884) and Augustin Morel (1809–1873), later popularised by Paul Möbius (1854–1907) and the Hungarian-born physician Max Nordau (1849– 1923). This perception of modern civilisation and degenerationist theory in particular came to be widely accepted by psychiatrists by the last third of the nineteenth century.87

The Hungarian Model At a time when the free treatment of mental patients was already prepared in civilised countries, the insane were still completely left alone in Hungary, partly exposed to ridicule, poverty and death, and partly endangering social safety, which situation could only be solved by closing up the most dangerous mental patients in prisons where they languished among prisoners until merciful death delivered them from their sufferings. Only a few patients found space in remote hospital cells and a very few patronised persons were admitted to the Viennese lunatic asylum permitted by the court chancellery.88

Hungarian psychiatry partly developed in line with the general trends described in the first part of this chapter and partly deviated from them due to its specific conditions. Specialised institutions that provided care for the mad in great numbers emerged comparatively late. Until the middle of the nineteenth century, most of the insane probably roamed freely, were cared for at home, locked up in prisons or kept in hospital wards (including those run by the Church) without adequate medical attendance. Even though much further research is needed to recover the conditions of the mad in the period prior to the birth of specialised institutions,89 it seems clear that due to the generally low number of doctors, apothecaries as well as caring institutions in the country during the eighteenth and first part of the nineteenth centuries,90 traditional Hungarian rural society dealt with madness with its own means. Folk medicine had a strong tradition in the Hungarian Kingdom. In György Gortvay’s words,

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people shared a “boundless trust” in home drugs and traditional forms of healing (use of smoke, steam, ointments, teas, different spirits, herbs, etc.). Even at the end of the eighteenth century, “home curing” was widespread: most families and village clergyman would own a herbal and a small house medicine chest.91 Folk medicine also provided its own broad market of healing experts. The conscience-racked souls could seek help from clergymen who were active not only in caring for the soul, but also in providing physical healing to the sick. A holy fool or a witch could also lift a curse, and people heavily relied on the services of unorthodox healers, like quacks (agyrtae), wandering healers (histriones, Marktschreyer, circumforanei, circulatores ), peddlers selling secret substances, hand-readers (chiromantia), wandering herbalists and barbers, wise women and cunning-men. The governing body of the Kingdom, the Council of General-Governor (Helytartótanács 92 ) as the chief national public health authority sought to extend its control over drawing the boundary between authorised and nonauthorised healers, orthodox medical experts and “quacks,” and in 1770 issued the Generale Normativum in re Sanitatis (Basic Health Care Regulation). In practice, however, unorthodox healers could not be supressed in the country even during the first part of the nineteenth century.93 Wealthier families in the countryside who could pay for a doctor’s visit as well as town people had a better chance to consult a university-trained physician who would probably offer medications and a health regimen, or use bleeding and purging even for afflictions that would be qualified today as mental illness.94 A more systematic care for the mad was first undertaken by religious orders. State initiations of custodial care appeared in the second part of the eighteenth century in the framework of general public health and hospital care provision as well as poor policy, although these initiatives first failed to achieve much. The private provision for the insane did not become a pattern, in part probably due to the prevailing feudal economic structures. The first viable private lunatic asylum was established as late as 1850. The rest of this chapter is divided into four units. In the first, I deal with religious and state-organised arrangements for care in the late eighteenth and first part of the nineteenth centuries. I briefly discuss the case of the Eger Hospital of the Hospitaller Order as an example of religious care for the insane in the country. Then I elaborate on early state

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endeavours at the organisation of public health and hospital care—initiatives closely linked to poor policy. This will be complemented with data concerning the general supply of doctors and hospitals in the period. I end with an outline of the emergence of the first specialised institutes: lunatic asylums, private and public. In the second section, I focus on other areas pertaining to the process of medical (and psychiatric) professionalisation in the Kingdom. These include: some major characteristics of the history of medical training in Vienna, also closely followed in Budapest, and the establishment of medical forums, all in the context of Magyar nationalism. The third section deals with the period starting in the 1860s as I demonstrate the energetic increase in mental asylums and hospital psychiatric wards within the boom in general medical institutions due to reforms introduced in hospitals and the public provision of health care. I discuss legislation pertaining to the insane in the context of related laws and decrees concerning general health care and hospital care for the poor. I briefly outline the institutional fragmentation that began during the outgoing years of the nineteenth century. Finally, the fourth section focuses on psychiatry’s place in the general nineteenth-century processes of the scientific revolution in medicine and medical specialisation and professionalisation. Care for the Insane in Hungary from the Late-Eighteenth to the Middle of the Nineteenth Century On 28 January 1754, Empress Maria Theresa sent an ordinance to the Council of Governor-General about the case of István Korvini, an “insane person” arrested in Pozsony for flooding and pestering the Hungarian Treasury with letters.95 The Empress ordered an investigation whether he was truly insane or a delinquent; in the former case, he would be escorted back to his domicile in Trencsén county and taken care of there. Two weeks later, Trencsén county sent a response to the Council of GovernorGeneral stating that Korvini’s mental disorder had been known by the county administration since he had already been “in the care” of the county. Occasioned by an earlier bout of madness, he had been taken to his mother’s house in Vágbeszterce. Within a few weeks, however, Korvini escaped from his mother who had also suffered from insanity for years.96 In another letter to the Council a few days later, the county admitted that the isolation of the mad who were dangerous to the public was of

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common interest, however, the county was not able to care for such persons financially. Other ordinances and responses followed. In one of these, dated 9 April 1754, the sub-prefect of Trencsén county suggested that the patient be placed in a hospital where adequate care was available. What actually happened to Korvini is not clear from the sources, but, according to a 15 May 1755 ordinance of the Council, issued at the request of the Empress, the patient must be provided with better food and adequate medical assistance. Within two months, Trencsén county gave more information on the patient. István Korvini was in fact called István Harván, born in Vágbeszterce; a quiet and “honest man” before he went mad decades earlier. He then began pestering the noble lords with petitions and was locked up in the prison of Trencsén castle. As the report stated, he had “no problem other than” claiming that “royal blood was running through his veins” and believing to be the descendant of King Matthias Corvinus97 (hence his chosen name Korvini), although in fact he came from a rural family background. Harván then must have been taken to custody somewhere, since we learn from an ordinance dating from two years later (4 August 1757) that he was to be let free if he was not dangerous anymore, so that he could beg for bread. In a few days, the Council ordered the county to take care of Harván at public expense. Within a month, Trencsén county reported that the county administration voted for supplying the patient with one-pound meat per day and some bread.98 This fragmentary account reveals much about contemporary conditions of dealing with insanity. First, madness certainly became an issue for the authorities if the person turned bothersome. If behaving in atrocious ways, the insane had a good chance of being locked up in a prison. If found mad, the county was supposed to take care of him, which often entailed that the person was entrusted to the care of his relatives. The intention to place the insane person to a hospital and provide him with medical attendance was not lacking, but institutions certainly were. Finally, after years of madness and possible confinement in either a prison, workhouse or some healing institution, if the person was no longer dangerous, he or she could be simply let free to beg for bread and try to sustain himself. In case the county was pressed by government authorities, it might provide the insane with daily food portions. To draw a more adequate context for the above case as well as contemporary conditions of taking care of the insane, in the following I first discuss available religious care and then early attempts at the organisation

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of public health and hospital care in the Hungarian Kingdom as well as the Empire. Religious Care: The Eger Hospital of the Hospitaller Order In the Hungarian Kingdom Catholic religious orders were the first to provide some form of “systematic” care for the mad.99 In the eighteenth century, the Hospitaller Order (Irgalmas rend) was the most active in hospital building. With its 100 beds, the Pozsony Hospital of the Hospitaller Order founded in 1672 (and rebuilt in 1723) was the largest hospital in the western part of the Kingdom. Hospitals by the Order were opened in Eger (1726), Vác (1780), Pécs (1796), Pápa (1757) and Buda (1809). By the 1830s, further hospitals were built in Temesvár, Nagyvárad, Kismarton and Szolnok.100 The most prominent case is that of the Eger Hospital of the Order, significant for two reasons. On the one hand, it is the first institute where the claim for some kind of a specialised care for the mentally ill is documented. On the other hand, in the second half of its eighteenth-century history, it became strongly connected to the establishment of the Eger Scola Medicinalis , the first medical school in the modern period.101 This hospital provided the “patient material”102 and space for teaching, and thus represented an early attempt at combining clinical observation and teaching. It also offered early care for the mad, though it did not become significant in terms of the numbers catered for up until the last third of the nineteenth century.103 Gábor Erd˝ ody (1684–1744), Bishop of Eger, established the Hospitaller Order in Eger and entrusted it with the treatment of patients in their hospital from 1728.104 It subsisted on foundation money and the Order’s income. The archival material of the Hospital contains references to a Narren Zimmer (room for the mad),105 which suggests that from the middle of the eighteenth century there were mad people taken care of at the hospital. A hospital at the time mostly meant an asylum for the poor and old with custodial, rather than therapeutic functions. But it is significant that, certainly from as early as 1758 (and possibly from even earlier), the Eger Hospital was directed by a doctor with a medical degree,106 practising with other doctors among his staff. Since the order belonged to the Austrian province,107 the doctors mostly received their training in Vienna.

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The data from the years 1767–1770 shows that on a regular basis there were 29 patients, while 24 monks worked as nurses and donation collectors, and 12 people comprised the service staff. Altogether 65 people lived in the Hospitaller convent. Its 29 beds seem few even if one considers that between 1728 and 1745 3,662 patients were cared for at the institution, out of which 265 died.108 Most hospital records suggest an early categorisation of illnesses based on different principles (dominant symptoms, the organic locus of affliction, etc.). Even if coherent mental disease categories were still not systematically introduced, there were patients regarded to be suffering from mental and nervous disorders. Among the 454 patients in the year 1769, there were four hypochondriacs as well as patients suffering from Anorrhexia, Obstructio mesenterii, Phrenesis , etc.109 According to the Historia Domus of the Eger Franciscans, their sacristan, Mózes Dánfi went mad in 1770. He was known as a sober and gentleman, but from the middle of February he turned confused and began to have delusions. He feared that he would be closed up and killed. His fears prompted him to try to run away several times, but he did not turn to rage. On 16th February, for the first time he did not celebrate mass. He was soon taken to the Hospital of the Hospitaller Order where his disease was diagnosed as mente captus. During his treatment between 1st March through 24th April, “their (the Order’s) doctor, Ferenc Markhot cured him.”110 On 2 September 1770, Markhot gave a lecture on the soul in front of the faculty of Scola Medicinalis, and one professor from the theology and one from the philosophy faculties took part in the debate as opponents.111 Although I found no document on the content and nature of the debate, Markhot’s organisation of the event with the involvement of the other faculties suggest an attempt to highlight and perhaps clash the distinctly different attitudes of theologians, philosophers and doctors towards questions of the soul and the mind. Within the walls of the newly established medical university, this move may both demonstrate the still existing authority of theology and philosophy in matters of the soul and be read as a medical attempt of appropriation of that authority. The hospital was an exclusively male institution, with treatment free of charge. People of all religious affiliation were accepted, and although priests were treated in a special room, men of all occupations were admitted, including forensic convicts. The hospital doors were open before locals as well as outsiders. In 1761, the Council of GeneralGovernor extended state discipline and surveillance over the work of the

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Hospitaller Order, and from time-to-time the hospital was inspected by town authorities and the bishop’s deputy.112 In 1784, Emperor Joseph II visited the Eger Hospital and made the Hospitaller Order the “caretakers of mental patients.” He issued a decree in the same year which ordered that all mad priests and monks had to be escorted to and taken care of in the closest hospital of the Order. Although Ringelhann sees this act as the start of “systematic treatment and care” of mental patients in the Eger Hospital,113 one must not overestimate either the professional qualities or the efficiency of care actually provided in the institution at the time (and, as a matter of fact, even later, in the nineteenth century). The number of available beds for mental patients, however, remained low, even if the ratio of beds for somatic and mental patients changed to the advantage of the latter. The Hospital was enlarged in the late 1870s–1880s, and by 1894, it had 80 beds for mental patients.114 The role of hospitals run by religious orders was continuous throughout the period observed in this book.115 The sheer number of beds at the end of the nineteenth century cannot be regarded as high compared to the population of the Kingdom; however, it still made up 4% of all available beds in mental institutions at that time.116 So far no sources have surfaced that would suggest an open conflict between the psychiatric profession and the Church for the monopolisation of the care for the insane in Hungary. Instead, there seems to have been a division of functions between institutions under different auspices. While psychiatric expertise moved in to religious hospitals (for instance, the eminent neurologist Ern˝ o Jendrássik was doctor at the Buda Hospital of the Hospitaller Order’s mental ward), both examples of the Buda and the Eger hospitals suggest that the Church retained its historical role of caring for those in the most desperate situation. By the end of the nineteenth century, the Eger Hospital grew into the country’s largest dumping ward for the most hopeless cases, which served to ease overcrowding at large public asylums.117 Early State Initiatives in the Field of Public Health Care Financing Health and Hospital Care The organisation of public health and hospital care, and within this, the care for the mad, was strongly related to the policy towards the poor. While the systematic organisation of care for the sick and poor within the Empire was laid down in the neo-absolutist period of the 1850s, the seeds

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of organised public health care were planted already during the rule of the enlightened absolutist emperors in the late eighteenth century. The cost of health care from the earliest times was the responsibility of the local public administration, covered by local funds or cassas (házi pénztárak). Accounts of these cassas collected by the Council of Governor-General, however, suggest that before 1848, public health care was provided mostly for convicts and county servants.118 A royal ordinance from 22 August 1724 stated that every community (község )119 was responsible for taking care of its own poor. In 1768, an ordinance devoted the income of the cassa parochorum to the establishment of hospitals; this was a budget drawn from the property of clergymen who died without testament, and a part of the salary of church dignitary positions that had fallen vacant. In 1775, guilds were ordered to support their sick and poor masters, journeymen and their families with the guilds’ own means.120 Other imperial resolutions clarified the mutual conditions of patients’ treatment between the different territories of the Empire. The treatment of Hungarian patients in hospitals in other parts of the Empire was free of charge for instance, just like the treatment of other imperial subjects in Hungary. This, however, did not apply to mental patients. In 1812, a resolution expelled Hungarian mental patients from the hospitals and asylums in Vienna, Prague and Lemberg, claiming that Hungary could not return the treatment to these countries, since she did not have an asylum. An important reason behind this decision must have been the overcrowding of these institutions, since the resolution also refused Hungarian paying patients.121 Imperial policy of co-ordination and standardisation across the Empire based on mutuality and seeming equity put pressure on Hungary to set up asylums, but for various reasons discussed below no such public institutions were established before 1868. During the neo-absolutist period, a systematic design of health care within the Empire began: Hungarian municipal authorities were deprived of their previous status in 1849 after the failure of the war of independence, and the “local funds ” (házi pénztárak) were abolished in 1850.122 According to general state policy within the Empire in 1851, the Chancellery was managing problems and costs pertaining to the entire empire and not the individual countries. The costs of public care for the sick were covered by a “national fund” (országos alap) which was supplied from taxes and used for the management of public investments such as roads, bridges, water-supply, gendarmerie, military lodgings and public health. The accounts of the national fund from the years 1852–1853

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show however, that only a very small portion of the funds was in fact used for the care of the sick (most of these only covered apothecary invoices and doctors’ daily fees), but it greatly increased with the development of public health care in subsequent decades.123 An 1852 writ124 from the K.u.K. Council of Governor-General to the Finance Ministry clarified that care for physical and mental patients in hospitals and asylums was only covered from the national funds if the person’s poverty was officially proved by local authorities. In 1854, the K.u.K Ministry of Interior ordained that the costs of care for the poor in Hungarian hospitals be taken over by the local national funds of the patient’s domicile (each larger administrative territory having “national fund” of its own).125 Another ordinance in 1855 specified the responsibilities of the patient’s local administrative authorities to ensure hospitals that their costs of care and treatment were met for those unable to pay themselves.126 In January 1854, the Habsburg Empire joined the July 1853 Eisenach Treaty, which settled mutual health care among the German provinces, thereby establishing mutual hospital care free of charge between the Empire and the German provinces (in case of poor patients). Within the Empire, the reciprocity of free medical care was modified in October 1855. While the requirement of mutual care for patients from other areas was retained, the costs of poor patients had to be covered from their respective national funds (while a more detailed documentation of the patient’s poverty was required).127 In 1855, a systematic survey was undertaken to map which healing institutions should be qualified as public hospital and thus be entitled to rely on the support of the national funds. Such public hospitals were in town or county ownership or placed under the national Chancellery. They were supervised by the authorities and obliged to accept not only local but foreign patients. In such institutions the state took on hospital costs in advance and, in case of irrecoverable costs, met them from public funds. Private institutions were not forced to take in foreigners or patients whose disease did not fit the institute’s profile, except for syphilitic patients (bujasenyvesek) and perilous cases, where the state accepted the costs under any circumstances. After the survey was completed, a final resolution by the K.u.K. Ministry of Interior systematically settled these aspects of public hospital care in December 1856.128 According to Gábor Gyáni, the 1856 separation of hospitals and poorhouses signified a major shift in the history of social hygiene: it is since then that we can talk about a

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general public health care in the country.129 After the reestablishment of the Hungarian Council of General-Governor in 1860, several resolutions were passed, aimed at a more efficient collection of provision costs from families and local funds.130 Doctoral and Hospital Supply In spite of the attempt of the imperial authorities at organising public health and hospital care, well into the nineteenth century, trained doctors were not available for most segments of the society and only a few healing institutions existed.131 In 1724 and 1750, the Council of GovernorGeneral made surveys to map the doctor supply in the Hungarian Kingdom: merely 37 doctors (most of them of foreign origin), 19 pharmacies and approximately 120 surgeons were found in the entire country. Counties like Máramaros, Ung, Zemplén and Bereg, for instance, could not boast with a single doctor or surgeon even in 1760.132 The Council therefore urged counties to have at least one trained doctor and every district (járás ) to keep at least one surgeon and a midwife. While the poor population in the countryside had no access to doctors, noble landlords, church authorities, towns and counties were eager to seduce doctors from each other.133 With no medical training in the Kingdom, physicians and surgeons mostly came from Vienna. After many aborted attempts at the establishment of a medical teaching in the country, eventually Maria Theresa founded the Medical Faculty at the Nagyszombat University in 1769. Regarding the number of doctors, the faculty did not make an immediate impact, but its long-term influence is considerable (see discussed below). Compared to the 37 doctors and 120 surgeons in the decades of the 1720–1740s, by 1830, about 640 doctors and 1,276 surgeons worked in the Kingdom.134 Even if the number of doctors increased considerably, this could hardly keep up with population growth discussed below.135 The country had very few healing institutions before 1800. There were only 34 hospitals (with a generally low-quality medical care) and poorhouses in the entire country, offering 1,590 beds, two-thirds of which were concentrated in two towns: the Pest town hospital had 600 beds, the Pozsony Town Hospital 224 and the Pozsony Hospital of the Hospitaller Order 108 beds.136 During the five decades between 1800 and 1848, the number of beds almost doubled: 58 new hospitals were built with 1,328 beds.137 In 1863, the total number of hospital beds in the country amounted to 3,600, which constituted only 1/8th of the hospital bed

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supply in the Empire, while more than 1/3rd of the Empire’s population lived in Hungary (excluding Transylvania).138 Many public hospitals admitted mental patients from the 1820s. Therapeutic prospects, however, must have been disappointing, considering the lack of trained mental pathologists at hospitals as well as the poor conditions of care. In most hospitals, small separate cells were designated for the mad. In the Pest Saint Roch Hospital, for instance, the insane were kept in cages in six dark cells built in the courtyard. If there was no room there, freshly admitted deranged patients were mingled with other patients and if they did not recover within a month, they were simply discharged from the hospital.139 In 1850, the director of Saint Roch Hospital wrote to Ferencz Koller K.u.K. Counsellor, reporting that so many insane patients were taken to the hospital that they did not fit the rooms reserved for them and the chief doctor was compelled to refuse many patients who could have been cured in a better institution.140 The Pápa and Gyula public hospitals regularly admitted mental patients from 1837 and 1840, respectively. These wards, however, were not equipped for many patients. In the Pápa hospital, for instance, only 62 mental patients were treated between 1837 and 1843.141 By 1869, among the 19 county and town public hospitals enlisted by Grósz, 17 hospitals had rooms for mental patients, but most of them had facilities only for 2–8 patients.142 Lobbying for Asylums “National Madhouse, Thy kingdom come!”143

From the second part of the eighteenth century, the most significant objective concerning mental health care in Hungary targeted the establishment of a national asylum. The endeavours came from different directions: the Austrian imperial court, high-ranking Church authorities, aristocratic circles and medical professionals. Emperor Joseph II, founder of several Austrian hospitals, already realised the pressing need for a national lunatic asylum in Hungary. Several edicts testify to his attempts to improve the conditions of the poor and the ill. Under his successor, Leopold I, 300,000 Forints were allocated in 1791 for the building of the national asylum on Viennese model, from the property of the monastic orders confiscated by Joseph II (fundus confraternitatum).144 But due

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to the lack of money, war and other social and economic reasons, the construction works did not start until seven decades later. The early history of Hungarian psychiatry is reflected in a list of failed attempts and aborted initiatives, petitions and requests that slowly wandered from the town and county magistrates to the Chancellery, the Council of Governor-General and the “Ofener Magistrat.”145 In a petition to the palatine in 1801, for instance, Pest county requested that a sector of the hospital in Szentendre be transformed to care for mental patients. At the same time, Pest asked for a large building from the county to be turned into a lunatic asylum. In 1806, Chancellor Count Pállfy encouraged the Council of Governor-General to offer a proposal for the establishment of an asylum. As a result, Endre Pfisterer protomedicus designed an asylum for 70 patients by 1809, with two separate buildings, one for calm patients, the other pro furiosis maniacis. It only remained a plan. In 1819, Pest county sent another petition to the Palatine, stating that the Emperor had already rejected their request for a lunatic asylum for their county, stating that “a public fund will be established for similar purposes.” The county found the building of its own asylum necessary since the mentioned institution would certainly be postponed due to financial constraints, and “the county’s lunatics remain without care, whereas His Majesty forbade the keeping of mental patients in gaols.”146 The petition again remained without success.147 When a considerable sum was collected due to public contributions and a rich fund set up by Count Ferencz Nádasdy (Bishop of Vác and later Archbishop of Kalocsa), other problems delayed the project. Epstein enumerated the historical and natural factors that inhibited its realisation: first, the French war and the ensuing devaluation, then the death of the protomedicus in 1825, the Danube’s flooding Pest in 1838, “all impeding factors that delayed the cause” for years. The 1848–1849 Revolution and war of independence did not favour the case of the asylum either. Epstein believed that the reason for the “miserable conditions” was not the lack of sensitivity towards such problems, rather “the nation’s political and social disorderliness and the subsequent cultural and financial backwardness.”148 In spite of all these endeavours, the national public institution was not born until the second part of the nineteenth century. Thus, around 1800, when the “trade in lunacy” was flourishing in England, and when reforms of the custodial asylum opened a new, hopeful era of the therapeutic

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asylum in England and France, Hungary still lacked a mental institution. The reason why there was no such boom in private asylum building as in the West is largely due to Hungary’s late industrialisation and lack of entrepreneurial initiatives. The situation was not alleviated by private asylums either, since the first such institution was founded only in 1841. After the nonviable initiative by József Pólya, whose small asylum catered to 10 lunatics and only survived for a couple of years (finally closed for financial reasons),149 only one institution, the Buda Private Lunatic Asylum—also called the Schwartzer asylum—emerged in the private sector before the end of the nineteenth century. Not before 1900 did a few specialised private mental institutions turn up with a wave of new sanatoriumfoundations.150 Whereas there was certainly a boom in the turn-of-thecentury private nerve-clinics, most of these institutions explicitly excluded mental patients.151 Therefore, the private management of the mad did not become a pattern in Hungary before 1900.152 Standing alone, the Schwartzer asylum (with 150 beds throughout the period) proved to be a viable enterprise, with significant impact on the development of Hungarian psychiatry.153 When the first criticisms of the therapeutic asylum were heard in the West in the 1850s,154 Hungarian doctors were still lobbying for the national institution. In a resolution in 1857, Francis Joseph I finally declared the building of the Hungarian National Lunatic Asylum as indispensable and designated 315,000 Forints for this purpose from the building fund of the Buda Castle.155 The construction process was an enormous undertaking, with several interruptions and problems concerning fraud. After much strife, the national madhouse was finally established in 1868. It was christened Lipótmez˝ o State Lunatic Asylum and has since existed in the public mind simply as Lipótmez˝o.156 Medical Teaching and Professional Forums Prior to the establishment of the first Medical Faculty in the Kingdom in 1769, students intent on studying medicine were forced to go abroad. Private medical teaching certainly existed, but it did not provide a degree, only a basic knowledge, liable to help aspiring students to earn their degrees more easily in foreign lands.157 Physicians and surgeons mostly came from Vienna. Due to Gerard van Swieten’s reforms in 1749, the Viennese Medical Faculty emerged as a major German language centre for

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medical training by the second part of the eighteenth century,158 which was attended by a sizeable group of students from Hungary. The need for a Hungarian medical faculty was strongly voiced by the middle of the eighteenth century by the Hungarian Diet, high-ranking church officials, members of the aristocracy and medical professionals as well.159 However, most of these attempts were impeded, rather than supported by the Austrian Court, as royal modernising endeavours in the sphere of medical education clearly subordinated Hungarian interests to Austrian ones within the Empire. To prevent the rise of a rival institution, the Viennese Chancellery kept postponing, for instance, the establishment of a veritable medical school in Eger.160 In the 1760s, there were indeed plans to develop the Eger Lyceum into a university with four faculties, strongly supported by Count Károly Esterházy, Bishop of Eger, Ferenc Markhot, chief physician of Heves county and János Perliczy, chief physician of Nógrád county. Maria Theresa nevertheless obstructed the process, permitting medical teaching at the Eger Scola Medicinalis only in 1769. The institution provided academic teaching in medicine free of charge, but only to students with a philosophy diploma. In many ways, it operated up to European standards: Boerhaave, Van Swieten and Haller’s works were taught, and theoretical and practical teaching was equally emphasised, as the Eger Hospital of the Hospitaller Order served the patients for clinical teaching. The Scola Medicinalis soon declined in the shadow of the Nagyszombat University completed with a Medical Faculty proper in 1769 and closed its doors in 1775.161 Predecessor institution of today’s Eötvös Loránd University, the Nagyszombat University was originally founded in 1635 by Péter Pázmány, Archbishop of Esztergom. Placed under royal control and the surveillance of Council of Governor-General, the former Jesuit church institution was secularised and turned into a state university by Maria Theresa. It was moved first to Buda in 1777/78 and then Pest in 1784/85. Maria Theresa granted the Medical Faculty the exclusive right to issue a medical degree in the country in 1770.162 In spite of its subordination to the Viennese faculty for many decades, it was instrumental in forming the bulk of a Hungarian medical community and consolidate its own medical tradition by the end of the nineteenth century. The institution had a growing impact on the training of medical personnel available to the public. Although only seven students matriculated in the first year, between the years 1781/1782 and 1785/1786

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(already in Pest), the registered doctoral students’ yearly average was 26, which increased to 88 by 1820–1825.163 Table 2.1 demonstrates changes in the size of the student body at the Hungarian Medical Faculty in comparison with the number of Hungarian medical students registered in Vienna in the period between 1820 and 1850.164 Table 2.1 shows a considerable fluctuation in the size of the student bodies at both faculties. The most striking characteristic is the low number of Hungarian students studying in Vienna compared to Pest throughout the period. Between 1820/1821 and 1847/1848, out of all Table 2.1 Number of students enrolled at the Pest Medical Faculty and Hungarian medical students at the Viennese Faculty, 1820–1850

1820/1821–1824/1825 1825/1826–1829/1830 1830/1831–1834/1835 1835/1836–1839/1840 1840/1841–1844/1845 1845/1846–1847/1848 1848/1849 1849/1850 1850/1851

Students at the Pest Facultya (Yearly average)

Hungarian students at the Viennese Facultyb (Yearly average)

Doctors

Surgeons

Doctors

Surgeons

88 250 383c 334 248 208 – 167 194

194 273 406d 273 241 136 – 103 131

30 58 42 138 89 63 32 32 120

27 31 11 42 25 13 4 2 12

Sources a These numbers are calculated based on the yearly number of registered students at the Pest Faculty, provided in Endre H˝ ogyes, ed. Emlékkönyv a Budapesti Királyi Magyar Tudományegyetem Orvosi Karának múltjáról és jelenér˝ol (‘Memorial Book’ on the Past and Present of the Medical Faculty of the Royal Budapest Hungarian University) (Budapest: Athenaeum, 1896), 123. b These calculations are based on a systematic survey of Hungarian students in Austrian universities. See László Szögi, Magyarországi diákok a Habsburg Birodalom egyetemein. I. 1790–1850 (Hungarian Students Studying at Universities in the Habsburg Empire) (Budapest-Szeged, 1994), 93–149. Szögi’s survey provides the names of individual students in the year of admission. Since these entries signal first registrations only, I multiplied it with four to gain an estimate of the annual Hungarian student body at the faculty. (Medical training by this time consisted of 5 years, however, some students obviously spent less time there without completing their studies, while others might have stayed for even longer.) These numbers are rough estimates that further research should confirm. c The climax is in year 1832/1833 when 418 doctoral students were enrolled. H˝ ogyes (1896), 123. d The climax is again in year 1832/1833 when 494 students were enrolled in surgeon training. H˝ ogyes (1896), 123.

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medical students from Hungary, 78% received training at the Pest Faculty and only 22% in Vienna. This demonstrates a remarkable dominance of the Pest Faculty regarding the choice of Hungarian medical students during the Reform Era, although the proportion is still rather surprising, especially if one compares it to similar data from the early 1880s. In the years 1880/1881–1884/1885, 54.0% of all students from Hungary studied at the Budapest Faculty as against 34.8% in Vienna, 6.1% at the Kolozsvár Faculty established in 1872 and 5.0% in other countries.165 The proportion is even more striking in case of surgeons between 1820/1821 and 1847/1848. From all students seeking surgeon training, 91% chose to study in Pest and only 9% in Vienna. The reason seems to be obvious: the more difficult and prestigious 5-year doctoral study required a more serious investment than the two-year surgeon training, especially if undertaken in Vienna rather than Pest. Those who chose the Viennese Faculty were more likely to come from the more ambitious and probably wealthier group of medical students. At the Pest Faculty, surgeons outnumbered medical students until 1830–1835, after which the tendency changed. This was most likely due to the wider market for lesser-trained surgeons in the earlier period to quickly ease the lack of medical professionals in the country. The Hungarian Faculty’s curriculum and examination system followed the Viennese model and was reformed several times during the period.166 In 1786/1787, a new study-system by Joseph II unified doctors and surgeons’ training and decreased it to four years.167 In order to meet the urgent need for surgeons in villages and small towns, a separate, two-year track was defined for “civil” and village surgeons (Civil und Landärtze) with the requirement of four-year secondary school education. The 1807 Ratio Educationis Publicae 168 raised doctoral training to five years again (renaming it: doctor-surgeon education) and added the study of eye-doctoring in the third year and veterinary therapeutics in the fourth. The special tracks (two-year surgeon training and specialisation in eye-doctoring and obstetrics) were untouched.169 These reforms in the curriculum with the separation of different educational tracks aimed both to improve general medical training while at the same time also to satisfy the immediate need for lesser-trained professionals in the country.170 The year 1848 brought about enormous changes both in Vienna and Pest that were not rescinded in the neo-absolutist period and continued beyond 1867. Education was liberalised, the strictly bound system of successive courses was loosened, the compulsory teaching material based

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on selected books was freed,171 and former admission exams, dissertation requirements and the opponent system all were left out.172 The 1848 liberalisation also introduced the privatdocent system in the appointment of the teaching staff of the Medical faculty, which raised the number of lecturers, especially after the 1860s.173 The primacy of the Viennese over the Pest Medical Faculty in Central Europe was partly supported by the court and partly due to their different financial conditions. The 1774 reform entitled doctors that graduated from the Hungarian Faculty to practice in all the provinces of the Empire. However, in 1783, the Viennese Faculty demanded this exclusive right to itself: diplomas from other universities enabled doctors to practice only in the regions where they were issued.174 The Nagyszombat and then Pest faculty could never compete with the Viennese in terms of the size of their teaching staff, salaries, institutional spaces and equipment, the size and variety of patient material, clinics and related hospitals. During the Nagyszombat and Buda period, institutional spaces and equipment were poor. There was room only for lectures, and the chemistry professor had not even proper space for demonstrations. There were not enough corpses for dissection in anatomy and no satisfactory botanical garden for botanists. There was no patient material for clinical practice, and in 1775, only a few rooms were relinquished to this effect to the faculty at the town hospital.175 At around the time when Joseph II founded the modern Viennese general hospital (1784) that enabled the Viennese Medical Faculty to achieve excellence with Europe wide repercussions in the next decades, the Hungarian faculty was moved to Pest in 1784 and was housed— with all its institutes—in a Jesuit monastery on the corner of Újvilág and Hatvani streets. In Pest, not only a new hospital was not founded that could have provided patient material, but the faculty had to pay to use patients for teaching at the old, worn-down town hospital. Between 1800 and 1850, the university uselessly lobbied to acquire Saint Roch hospital for teaching. All of the medical and natural history institutes of the faculty, together with the small “clinics” and a few patients were crammed into a few buildings until the end of the 1850s.176 Nationalism and Medical Forums The cultivation of sciences in Hungary during Enlightenment Absolutism (cca. 1760–1790) was practically arrested by political events in the mid-1790s. War against revolutionary France and the dismantling of the

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Hungarian Jacobinic movement (1794) marked the beginning of an era of conservative restoration. In the field of the sciences, the production of scholarly works drastically decreased, the exchange of ideas was halted by severe censorship and restrictions on travelling abroad, and loan libraries were abolished.177 As a result, between 1810 and 1830 not a single meritorious medical or natural scientific work was published in Hungary, Gortvay claims (perhaps with slight exaggeration).178 Stifft’s Viennese conservative programme between 1803 and 1836 was described by Lesky as a “medical restoration program” against the “medical Jacobinism” of enlightened ideas.179 Medical teaching was greatly curtailed at both universities until teaching was liberalised in 1848. According to Gortvay, numerous Hungarian doctors emigrated (especially to Russia) to take up academic positions abroad, while many departments at the Hungarian university were headed by Austrian and German professionals.180 In such a political and cultural climate, no wonder that, during the Age of Reform, most endeavours in the sphere of medicine and the sciences tended to gain a characteristic Hungarian nationalist colour. This included in a period of strong national awakening the growth of efforts at the self-organisation of the medical profession on a nation-wide basis. Professional associations and natural science societies indeed started to mushroom. There was an urgent need for a medical association serving for the promotion of research in related fields. From the late-eighteenth century, the first possibility to organise the medical profession was provided by and within the Hungarian Medical Faculty of the University. The faculty comprised its actual inner members who formed the so-called college of professors (collegium professorom) as well as outer members: doctors with university degree who wanted to join the faculty and formed the “college of doctors” (doctores collegiati). There is, however, a long history of animosity between the two groups that prevented the Medical Faculty from turning into a representative organ of physicians of the country.181 An 1802 attempt at organising a society that aimed at the cultivation of the natural sciences and medicine was thwarted by the Viennese court in 1808.182 Following the Viennese model, the Royal Society of Pest Physicians was finally established in 1837 (it received its formal authorisation in 1841). Its membership increased from its original 14 founders to only about 45 within a year, but its real importance lay in the fact that it provided the impetus for other medical societies to be organised in the

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country. While the Pest Society of Physicians only allowed trained doctors among its ranks (separate associations were set up for surgeons and apothecaries), the emerging regional societies (eight until 1848) included surgeons and pharmacists as well who probably had a more prestigious position in the countryside than in the capital.183 The idea of a central association that would professionally co-ordinate the network, organise national congresses and other forums of scholarly interest, and would also serve the function of interest enforcement, soon arose by 1839. With its numerous external members, the Pest Society of Physicians assumed a centralising function while it never formally undertook the safeguarding of the profession’s interests on a national level.184 The two scientific societies that exerted great influence in nineteenth century scientific life were also founded in 1841. The Hungarian Physicians and Naturalists Society (Magyar Orvosok és Természetvizsgálók Egyesülete) and the Association for Natural Sciences (Természettudományi Társulat ) had doctors and scientists as members from all over the country. Their annual meetings and itinerary congresses were highly prestigious forums where eminent doctors and scientists held presentations, mostly in front of wide audiences. Their publications strengthened their sense of professional identity.185 Devoted to purely academic issues, the Royal Society of Pest Physicians survived after the 1848 Revolution and War of Independence, while the Association for Natural Sciences—after its ranks had been politically cleansed—continued its activities in 1850; the Hungarian Physicians and Naturalists Society resumed its normal operations in 1863 only. The Age of Reform also entailed the launching of the first Hungarian medical journals and serial publications. The monthly Medical Collections (Orvosi Tár), founded in 1831, was the very first medical journal published in the would-be national language that appeared continuously until 1848. Afterwards almost 10 years elapsed before the new professional weeklies Orvosi Hetilap (Medical Weekly) from 1857 and Gyógyászat (Medicine) from 1861 could fill in the lacuna in the field. In the next decades, numerous medical journals were launched. The organ of the Association for Natural Sciences: Természettudományi Közlöny (Natural Scientific News) published from 1869 was one of the most popular professional journals in the country. The National Public Health Society brought about Egészség (Health) in 1887 to acquaint wider reading circles with public health issues. The Klinikai Füzetek (Clinical Papers), founded by the psychiatrist Gyula Donáth in 1891, aimed at more substantial

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studies in clinical medicine. The Magyar Orvosi Archivum (Hungarian Medical Archives), which gradually appeared between 1892 and 1899, appeared under the aegis of the Academy of Sciences. As opposed to the more practical Orvosi Hetilap (Medical Weekly) and Gyógyászat (Medicine), it provided forum for longer, more detailed and thoroughly documented theoretical works by members of the Academy. Two general journals: Orvosok Lapja (Doctors’ Magazine) and Budapesti Orvosi Újság (Budapest Medical Journal) were launched in 1900 and 1903. As mentioned before, medical professionalisation in the country was regarded as a fundamental aspect of the national project. In the introductory note of the first issue of Medical Collections in 1831, the editors claimed that they satisfied a “great need” of the nation’s medical community by launching the journal. Referring to the numerous similar journals in other countries, they believed that “we must blush for lagging behind so much in this respect.” “So many enlightened and eager doctors bury with themselves the noble results of their rich experience” in the lack of a printed public forum.186 It was essential to have a forum that “unites, educates, and revives” within the nation where young doctors in the provinces, “far away from all scientific strife, are unable to clear and enlarge their knowledge, … and greatly disappointed, accomplish their work … with dangerous empiricism, without heart and zeal.”187 The journal therefore undertook the task of quickly spreading the latest developments in medicine. It also provided essential professional information. With the publication of the most important news: appointments, rewards, vacant positions, deaths, institutional conditions, scientific reports and achievements, the purpose was to create a modern professional forum and strengthen the cohesion of a medical community in the making. At the peak of the national awakening, the dominant intellectual elite— recruited in the Magyar minority (some 40% of the population) that formed the relatively largest ethnic group in the Kingdom—made this movement rely on Hungarian—regarded as the only language destined to be the common denominator of a heavily multi-cultural society. Due to practical but also political reasons, the language of medical teaching until 1860 was actually Latin, though legally Magyar became the official state language in 1844. Under Joseph II as well as during the absolutist rule of the 1850s, many subjects were taught in German. In the training of surgeons, Hungarian, German and in the 1820s, even Slavic languages

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(Slovak notably) were used, evidently, to satisfy the local interest in territories populated by large ethnic minorities, where it was essential that local surgeons and doctors could communicate with patients. After 1860, Hungarian became the exclusive language of teaching, except for a few courses also compulsory for surgeons.188 The emerging modern Hungarian intellectual elite self-interestedly appropriated the scientific field in the great project of nation-building, largely disregarding similar attempts on the side of other minority groups. The question of the national language gained fundamental importance in this context. Similarly to endeavours in other disciplines, the purpose was to create a Hungarian medical tradition which implied the task to “Magyarize” the medical terminology. The Orvosi Tár (Medical Collections) intended to stimulate Hungarian research and multiply scholarly publications in Hungarian via the translation of foreign studies in the national language. “The already bright generation has to learn the Hungarian medical language exactly as they once learnt Latin.”189 In 1833, the eminent doctor and editor of Medical Collections Pál Bugát (1793– 1865) compiled the first Hungarian medical dictionary. Bugát’s other works in Hungarian: Boncztantudomány (Science of Anatomy) (1828), Tapasztalati természettudomány (Empirical Natural History) (1837), Természettudományi Szóhalmaz (Natural History Vocabulary) (1848) are among the first comprehensive general Hungarian textbooks in medicine appearing from the early 1830s.190 Paradoxically, internal professional “Magyarization” gathered momentum first in the Reform Era, when the majority of doctors were of culturally alien background,191 and again during the neo-absolutist era marked by a strong trend of the forceful “Germanization from above” of intellectual life. After a failed war of independence, nationalist and historical thinking imbued the discourse of professionalisation. In this, the idea of an independent medicine of our “own” came to be strongly connected to the national interest. As explained in the editorial to the first issue of Orvosi Hetilap (Medical Weekly) in 1857, written by the distinguished public health reformer Lajos Markusovszky, the purpose was “the cultivation of medical science among us and by us,” for “the benefit of the nation,” and to create a forum for Hungarian professionals “to keep the interest in scientific development and national civilisation awake in all provinces of our country.”192 Markusovsky emphasised that the further development of what the ancestors left for this generation as a heritage was “our duty towards the nation.” It became part of

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the scientists’ professional credo to “help the spread and independent blossoming of sober and rational medicine”: The fate of recent years has changed the traditional life of our country and melted it with the life and fate of the Empire and the whole of Europe. The welfare and bourgeois transformation of our nation has to be based on the foundation of a new age, by the cultivation of science, the industry and the arts; by nurturing and respecting individuality, purely human morals and merits – our nationhood has to develop on these paths.193

By this time, with more signs of nationalist awakening in some of the Kingdom’s other ethnic groups, the strategy of professionalisation aimed at the integration of all the participants in the same country-wide body of specialists: it acknowledged the multiple ethnic and language communities within the country whose contribution to the medical profession was not only unavoidable but even preferential (given the overwhelming share of assimilated “aliens” in the medical profession). “With patriotic trust,” the editorial repeatedly called “every doctor, pharmacist and friend of nature of all the tongues of Hungary and Transylvania to give a hand in improving the public cause.” But instead of propagating a multilingual intellectual forum, it expressed the wish to translate all articles written in other languages into Hungarian.194 Behind this vision, we can see the goal of centralisation: all achievements of the multi-ethic and multilingual nation were essential for the common interest, they had to enrich the common science and needed to be transplanted into Hungarian to fertilise the national intellectual soil. The Hungarian language, the centralisation of knowledge and information and the emphasis on the all-Hungarian national interest became the basic tools in this attempt of integration in the professional/scientific sphere. Centralisation was complemented with the strategy of systematic discovery and mapping, connecting and incorporating. Markusovszky’s editorial note quoted above launched the project of drawing the “natureand health map” of the nation. It encouraged county, district and village doctors to study and publish on the local specialities of the distinct provinces: on local natural characteristics, the local conditions of health care, aspects of the population’s way of living and socio-professional profile. Hospital doctors were asked to reflect on the working conditions of their specific institution and their patients’ diseases. All practising

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doctors were called for sharing their experiences by sending reports of instructive cases to the journal “for the enrichment of our science.”196 After the 1867 Compromise, the National Public Health Council (Országos Közegészségügyi Tanács ) was established within the Interior Ministry in l868 with the crucial role of organising public health care country-wide. According to the Prussian model, it was an independent advising body comprised of eminent representatives of different fields, supporting the work of the Ministry in health care issues, preparing laws and resolutions.196 The contribution of scholarly societies in the modernisation of public health care was of major purport, especially during the late 1860s and early 1870s when the Public Health Care Act was being prepared. (After the Hungarian Physicians and Naturalists Society resumed its normal operations in 1863, during their itinerary meetings in Pest and other towns in the following years, this task was continuously on the agenda. By the time the National Public Health Council was set up in 1868, there were several drafts. The bill was ready two years later but only passed in 1876.) The National Public Health Society (Országos Közegészségi Egyesület) was formed in 1886 with the function of acquainting the wider reading public with public health issues (in 1888, it was followed with several affiliated agencies emerging throughout the country). While the National Health Council was an “administrative” body, the Society was rather a “social” institution.197 The psychiatrists’ endeavours to gradually organise their profession and form a new discipline in its own right necessitated legal reform in mental health care, the foundation of learned societies, journals and congresses. All of these were essential to claim expertise within the medical sciences and define their role in society.198 Although the first Hungarian medical journal, Orvosi Tár (Medical Collections), already provided space for articles on (the miserable) state of mental health care, the organs Orvosi Hetilap (Medical Weekly) and then Gyógyászat (Medicine) became the first forums for early psychiatric publications from the end of the 1850s. Schwartzer, Bolyó and Niedermann were from the older generation who first utilised these journals to widely discuss asylum conditions, mental disorders and therapeutic questions. All of the major subsequent medical journals founded after 1867 contain numerous writings by psychiatrists. From 1904, Orvosi Hetilap (Medical Weekly) regularly published an Elmekórtani közlemények (Mental Pathology Supplement) edited by Ern˝ o Moravcsik and Ottó

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Babarczi Schwartzer. More than two and a half decades had to pass after the publication of the first Hungarian book on mental pathology by Ferencz Schwartzer in 1858 until more modern comprehensive textbooks emerged from the late 1880s by Ern˝ o Moravcsik, Jakab Salgó, Jen˝ o Konrád, Jakab Fischer, etc.199 In 1896, Károly Laufenauer founded the department of Budapest psychiatrists within the Royal Society of Budapest Physicians, and from 1900, the National Congresses of Psychiatrists were held annually.200 Boom in Psychiatric and Medical Institutions (1860s–1920) Public Asylums and Hospitals Although Lipótmez˝ o has since been considered as “the national asylum,” it was, in fact, not the first public state institution of that sort in the country. The Nagyszeben Royal National Lunatic Asylum (hereafter often Nagyszeben or Nagyszeben Mental Asylum) in Transylvania preceded it in 1863 with 200 beds. It had, however, never assumed such importance as Lipótmez˝ o, probably because of its Transylvanian location and the fact that it mostly catered to the local population.201 The first director of both institutions was Emil Schnirch, trained in Vienna, to be followed by the Schwartzer students Gyula Niedermann, Károly Bolyó and Jen˝ o Konrád. Since Nagyszeben and Lipótmez˝ o soon became overcrowded with incurable and dangerous patients which greatly undermined the possibility of cure, the state decided to establish a third public asylum specifically for this group of mental patients. It was opened in Angyalföld (Budapest) with 254 beds in 1884.202 Originally, the Angyalföld Mental Asylum was to admit only incurable and dangerous mental patients, but, in practice, it admitted curable patients as well. To ease overcrowding, the government provided 300 more beds for mental patients in 1896 by turning the old meeting hall of Szabolcs county in Nagykálló into a state asylum. Deprived of gardens and with its windows looking on to a busy street in the town centre, the Nagykálló asylum was heavily criticised from its birth.203 To rid state lunatic asylums of unpleasant associations (and suggest more modern conditions), all four of them were renamed as National Institute for Nervous and Mental Diseases in 1897.204 This growth in mental institutions was not an isolated phenomenon. State investments in health care were manifest in the building of new hospitals and the multiplication of hospital beds in the country. In 1867

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the general hospital supply was still low. There were only 44 hospitals and other healing institutes with 4,500 beds for a 13.5 million population.205 Development in the next decades was considerable in this respect: there were 398 hospitals with 42,543 beds for approximately 18.3 million people by 1912.206 Possessing 263 hospitals and 17,000 hospital beds for a population of 16.5 million in 1896, the Hungarian Kingdom was still low compared to the Austrian hospital and bed-supply: there were 625 hospitals with 38,000 beds in Austria with a population of approximately 17 million.207 The spectacular increase in the capital’s hospital supply was due to heavy state funding in the 1880s and 1890s. At the time of the 1867 Compromise, Pest and Buda had two large public hospitals: Saint Roch Hospital (Szent Rókus Kórház, founded in 1711) with 800 beds and Saint John’s Hospital (Szent János Kórház) with 150 beds. During the next decades, four new large public hospitals were built in the town, all within the framework of a large public health project. In 1885, today’s Saint Stephen’s Hospital (Szent István Kórház) opened with 700 (soon enlarged to 1,000) beds in a pavilion system on Üll˝ oi Street; in 1894, Saint Ladislas’ Hospital (Szent László Kórház) for contagious patients with 208 (soon 400) beds in eight pavilions and a disinfecting institute; in 1897, Saint Margaret’s Hospital (Szent Margit Kórház) with 100 beds in ancient Buda; and in 1898, the new Saint John’s Hospital (Szent János Kórház) with 450 beds. These institutions considerably improved medical provisions in the capital, clearly reflected in the lowering of the death-rates. Concerning patient admissions and death-rate at Budapest public hospitals during 15 years between 1875 and 1899, the number of patients treated there doubled (from 18,670 to 41,100 mean annual number of patients), while death-rate decreased from 11 to 7%. After the 1894 opening of Saint Ladislas Hospital (with pavilions for contagious diseases), the death-rate of contagious disease patients fell by 6% in 5 years.208 Still, the development of hospital bed supply hardly followed the increase of the capital’s population. As Table 2.2 shows, in spite of the growth, the ratio of patient admissions fell from 7.1% in 1873 to 6.0–6.5% until the end of the century.

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Table 2.2 Increase in number of beds, patient admission and Budapest’s population, 1873–1899 Year

Number of beds in 11 hospitals

1873 1876 1881 1885 1889 1894 1897 1899

1,501 1,659 1,923 2,374 2,455 2,568 2,628 3,155

Patient admission

Population of Budapest

Ratio of patient adm. compared to Budapest’s popul. (in %)

19,550 19,547 24,280 25,361 32,007 37,786 39,162 44,967

275,000 302,000 367,000 420,000 473,000 581,000 647,000 691,000

7.1 6.5 6.6 6.0 6.7 6.5 6.0 6.5

Source Based on numbers provided by Emil Jurkiny, “A székesf˝ ovárosi közkórházügy fejl˝ odése” (The Development of Public Hospital Care in the Capital), Egészség (Health) 9 (1901): 209–210

Legislation for the Insane State initiatives to develop public health care was also reflected in contemporary legislation and were strongly connected to the policy towards the poor.209 The most significant law of the Constitutional era in this respect was the 1876 Public Health Care Act, hailed in recent accounts as an outstanding achievement for its comprehensive character even from an international perspective, although in different areas its implementation was not successful.210 The Act, however, was not the only important law in this field. Some previous and subsequent acts also improved the care and medical treatment of the poor. These related laws are of two types: those concerning local community matters211 and those related to the costs of hospitalisation of poor patients. The 1871 XVIII Community Act (together with the 1886 XXII Second Community Act which basically strengthened the first Act) clarified the community’s role and responsibilities in taking care of its poor, including poor patients whose family could not meet the costs involved. This benefit of community care was based on domicile (illet˝oség, birthplace or other requirements). In a country characterised by energetic inner migrations (notably urbanisation) in the Dualist period, the definition of domicile necessary for entitlement to community care was fulfilled after two years’ living in one place and paying tax there. The 1886 XXII

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Second Community Act defined the condition for automatically acquiring domicile in four-year living and tax paying in one place.212 If the community was unable to care for its poor, the town or the county, and in the final case, the state took over the charge. As György Kövér also stresses, this logic of defining responsibility that builds on institutions and authorities from below up characterised the care for the poor in the Dualist period.213 The 1875 III Act on covering the costs of patient care and treatment systematically laid down the principles of state and community provision of medical care in public institutions. In the case of poor patients, the following persons were required to meet the costs incurred: a. parents for their children; b. children for their parents; c. the married couple for each other; and d. the employer for his maid; factories for their workers for 30 days; the owners of larger companies and the directorate of the railway company for their workers (with the right to subsequently recover the costs from the employees). In case the patient and relatives were poor, the costs were imputed to the municipal authorities of the patient’s domicile.214 The outline of the method of collecting payment for costs in the 1875 III Act was highly bureaucratic and aimed at ensuring that communities took financial responsibility for poor patients incapable of paying. It also regulated communication between the medical/caring institutions and municipal authorities.215 In order to ensure that public medical institutions did not get overcrowded by incurable cases, the 9th paragraph stated that communities were obliged to take over patients for further care. No state funds were available for the transportation of these poor patients.216 This 1875 III Act already dealt with the mad. While it did not require that curable insane patients be treated in public mental institutions (as the 1876 Public Health Care Act did), the 8th paragraph of the Act already expelled from public mental institutions poor patients found incurable but not dangerous to the public, together with “idiots,” “imbeciles” and “cretins”. Their care had to be organised by the local community. The Act also clarified that poor mental patients could only be admitted to public asylums at public expense (i.e. on state money if the community was unable to cover the cost) with the prior permission of the Interior Ministry.217 The 1876 Public Health Care Bill was passed after years of preparation by professionals (including many doctors from the National Public

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Health Council).218 While many resolutions of the Act directly aimed at improving the medical care for the poor, the six paragraphs of Article X entitled “Asylum care” is most important for the insane. It came to be known as the first mental health care law in Hungary and declared that “all curable and incurable mental patients dangerous to the public order (were) to be taken to lunatic asylums for the purpose of treatment or care.” At the same time, other incurable mental patients together with “imbeciles” and “harmless idiots” were to be entrusted to their relatives (at their own expense) or, if the relatives were also poor, to the community of domicile.219 The Act also tried to guarantee the medical standards of admission. It declared that nobody could be admitted to a lunatic asylum without a certificate of his/her mental illness issued by a doctor holding public office and by the patient’s previous doctor who treated him.220 With this ruling, the Act strengthened a rule already outlined in asylum foundation documents. According to the basic regulations of private institutes (Pólya’s 1843 and Schwartzer’s from 1850) as well as public asylums (Nagyszeben from 1863 and Lipótmez˝ o from 1868), at the time of admission, these institutions required a certificate or expert opinion by a doctor concerning the patient’s mental illness as well as the purpose of asylum care/treatment.221 Importantly, the 1876 Act introduced the “observation-system” to public asylums: every patient was only temporarily accepted until, after an observation period, his or her mental illness was confirmed. Then the patient was permanently admitted at the personal responsibility of the director who was required to send the medical findings to the patient’s court of competent jurisdiction without delay. In private asylums and hospital mental wards, a different set of rules applied: a patient was permanently admitted after a court ruling about his/her mental illness.222 Thus, in these institutions, courts had to be notified of the admission of patients immediately.223 If relatives had doubts about the person’s mental state, they had the freedom to convene medical experts at their own expense, but only before the court declared the person mentally ill. These experts, however, could only be chosen from the Medical Faculty of Budapest University or from among the members of the National Public Health Council.224 The Act also stated that “personal restraint and coercive tools” could only be used “in case of necessity, for the defence of the patient and others,” and only at the personal order of the doctor. Their use had to be suspended the

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moment it was no longer “necessary.”225 Finally, the Act stated that cured patients as well as persons who did not prove to be mentally ill during the observation period had to be immediately discharged.226 Although often criticised by psychiatrists in subsequent decades for its insufficiencies, Article X was not followed by further laws in the nineteenth century dealing more comprehensively with mental health care. At the National Alienist Congresses from 1900, eminent Hungarian psychiatrists believed that a comprehensive law was painfully lacking. While the emerging problems were dealt with in ministerial decrees,227 these could not substitute a more extensive legal treatment of the problem. Believing that “the regulation of mental health care involves strong restrictions on the individual’s personal freedom as well as touches civil law, its settlement has to happen via legislation,”228 the highly influential private asylum director and expert in legal matters, Ottó Babarczi Schwartzer, compiled a far more extensive and detailed new mental health care bill around 1900.229 As we have seen, in the Dualist period the organisation and legal regulation of mental health care grew out of and was closely interwoven with the organisation and financing of care for poor patients in public institutions. In the complex system of the division of responsibilities, a crucial aspect was the question of the mental patient’s dangerousness and curability. As a rule, the dangerous and curable patients had to be taken care of at mental asylums, while the care for incurable and not dangerous patients had to be organised by the communities. In terms of financial responsibility, it started from below and moved upwards: from the family through the community, towns and counties, up to the state. Crucial change in financing the care of poor patients in public institutions was made by the 1898 XXI Act which established a central national fund (Országos Betegápolási Alap).230 With this Act, the state took charge of the costs of poor patients’ hospital care. The 1898 XXI Act still kept the distinction between curable/dangerous and incurable but not dangerous mental patients: the latter still remained the financial responsibility of the community.231 The state, however, took over from the community the financial burden of poor patients’ care in mental asylums, hospitals as well as home (házi) care (the latter in the case the curable or dangerous patients’ home care as required by the authorities).232

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Pressure of Numbers and Alternative Institutions Energetic institutionalisation made the insane visible and statistically accounted for, while numbers gained special significance in the process of psychiatric professionalisation. According to the 1895 nation-wide survey, there were altogether 25,071 mentally ill people in Hungary (21,736 in the countryside, 1,852 in towns, and 1,483 in state asylums).233 This meant one mentally ill among 640 persons (1:640), a figure which the ministerial report claimed to have been much lower than in Western Europe (where the ratio was 1:300). This low ratio was attributed to methodological insufficiencies of the survey, people’s “hiding it out of prudery and sense of shame,” and the inability of inquirers to recognise the mentally ill. Even the ministerial report admitted that the number of mental patients in the country could be much higher (even the double than those registered.234 While this number was interpreted differently, psychiatrists in general accepted the Ministry’s approximations. New surveys in 1900 and 1901 counted cca 34,000–44,000 mentally ill in the country, which corrected the ratio of the insane in the population and gave a percentage closer to other European statistics: one mental patient for 390 people (1:390).235 These numbers are more revealing in comparison with the number of insane cared for in institutions supposedly providing professional treatment. According to István Hollós’ figures from 1909,236 before the Lipótmez˝ o Lunatic Asylum was opened in 1868, only about 500 beds were used by mental patients in Hungary.237 This number must have been somewhat higher (although not considerably) if the available beds at Schwartzer and Nagyszeben mental asylums, and the Eger and Buda Hospitals of the Hospitaller Order are included.238 By 1903, this number was almost 6,000 (at the end of 1903, 5,927 mental patients were cared for: 2,638 in large asylums and 3,289 at different mental wards annexed to hospitals239 ). Based on this, during 35 years, the number of beds grew almost 12 times,240 but it still meant that only a portion of the mentally ill, in fact, only every seventh mental patient, could be hospitalised.241 It is again revealing to make comparisons with Western countries. In England in 1800, in a population approaching ten million, about 5,000 mental patients were held in specialised asylums (and about as many insane in workhouses, bridewells and jails).242 A century later in Hungary, in a population about 1.7 times larger (16,830,000), similar numbers (6,000) were kept in mental institutions. By around that time in England (1896), 63,815 mental patients were treated on state money243

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(and probably a larger number altogether in public and private mental institutions; Porter suggests about 100,000 inpatients244 ). In Germany in 1900, 168 public institutions held 94,425 mental patients; in Italy in 1898, 128 institutions held 34,802 mental patients.245 Porter supports these numbers and stresses that growth in the number of institutionalised mental patients was especially vigorous in new nation states. In Italy about 8,000 confined in 1881 and 40,000 by 1907.246 There are also available numbers concerning the growth in the ratio of confined mental patients in the population of some Western countries. In Germany in 1852, there was one psychiatric inpatient for every 5,300 population and in 1911 one for every 500.247 In England in 1859, one psychiatric patient was hospitalised for every 625 people, and in 1909, one patient for 270 people.248 Compared to this, around 1900 in Hungary, one mental patient was hospitalised in psychiatric institution for every 2,805 population.249 In this light, one cannot speak of a large-scale provision of institutional care for the insane in Hungary even at the end of the nineteenth century. By the 1880s, large Hungarian asylums were overcrowded by patients, among them numerous hopeless cases. While lobbying for further asylums remained on the agenda well beyond the turn of the century, the state resorted to a highly criticised but much cheaper solution: forming “annex institutions” or “annex asylums” (mental wards attached to a hospital). Numerous such mental wards were set up in Kaposvár (1880), Szekszárd (1885), Gyöngyös (1896), Nyitra (1898) and Gyula (1898).250 Most psychiatrists found this choice absolutely untenable since, as Kálmán Pándy summarised in his fierce criticism: the two large state mental asylums got rid of their “incurable” patients by sending them to these inadequate facilities which lacked professional nurses and psychiatrists. Most mental ward doctors in the countryside had no training in mental pathology at all, and there was also no control of the patients’ admission procedure and conditions at the wards.251 Furthermore, annex-ward conditions could not be further away from those of the separate and spacious institutes surrounded by parks. Thus, when the government suggested to create new annex wards instead of large separate institutions at the 1900 National Alienist Congress, a fierce debate arose and most psychiatrists still voted for a separate mental asylum rather than the annex institution, heavily criticising the latter.252

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Therapeutic nihilism urged psychiatrists to look for alternatives in other types of institutions and psychiatric practices. Some progressiveminded representatives of the profession argued for the establishment of small institutions specialised in different areas on the model of tuberculotic clinics: institutes for epileptics, “imbeciles,” “idiot children,” criminals, alcoholics, epileptics, etc.253 Interestingly enough, such institutes emerged in the private sector, such as Blum’s institute for oligophrenic children in Pels˝ oc from 1898, Wosinsky’s Epileptic Colony in Balf from 1903, Niedermann’s Sanatorium in Rákospalota from 1903, Ringer’s Sanatorium in Kelenföld from 1906 and the Budapest Frimm Institute for “imbecile” children from 1908. The exception is the state-founded National Observation and Mental Hospital for Persons in Detention and Prisoners established for 140 patients by the Ministry of Justice in 1894, first temporarily by one of the metropolitan prisons, then from 1896 as a permanent part of the large transit prison (gy˝ ujt˝ofogház). The purpose of the institute was to relieve state asylums from forensic cases and collect arrested or convicted criminals whose mental state necessitated observation, cure or nursing.254 Such institutional fragmentation going hand in hand with specialisation was seen as beneficial for patients and advantageous for the profession at large. There was also a mounting advocacy of family care for the mentally ill and a propagation of alternative formations. Such were the colonies: usually spacious mental institutions set up on a large territory in the countryside. They consisted of many small houses rather than huge closed buildings and were mostly self-sustaining economic units organised around some agricultural or other occupation with work therapy functions. First in the country, the Dics˝ oszentmárton Colony was set up in 1905 some 70kms away from the Nagyszeben State Mental Institute and combined the characteristics of the colony with family care. It was followed in 1906 by the colony in Nagydisznód in the close vicinity of the Nagyszeben Institute.255 All this still reflected a very low level of institutionalisation in the country. Even if Germany’s population was roughly 3.5 times larger than Hungary’s in 1911, in Germany there existed: 187 public mental institutions (compared to 4 public mental asylums and about 27 public hospital mental wards in Hungary), 16 university clinics (2 in Hungary), 5 military psychiatric departments (none in Hungary), 11 forensic psychiatric institutions (1 such institute in Hungary), 225 private mental institutions

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and 85 nerve sanatoria (considerably less private institutions and sanatoria in Hungary).256 Modern Scientific Research and Professionalisation (1870s–1920) While the asylum was undoubtedly the cradle of psychiatry where the first doctors could acquire experience and knowledge in mental pathology and became self-conscious alienists with a sense of their profession in the 1850s and 1860s, we can also detect a declining trust in the institution of the asylum and a subsequent optimistic turn towards the university clinic and academic research. This turn was partly influenced by the nineteenthcentury revolutionary developments in medicine and scientific research (clinical medicine, laboratory and experimental research) described above, and partly came about due to internal professional needs. Professionalisation necessitated the foundation of university departments, the establishment of specialised training and career tracks and the production of psychiatric knowledge. Modern scientific research in the second part of the nineteenth century necessitated medical specialisation realised in department foundations and modern clinics. The idea that medical teaching should be complemented with clinical practice was already contained in Boerhaavian bedside medicine which became dominant in Hungary in the second part of the eighteenth century.257 Therefore, when the Hungarian Medical Faculty was moved to Buda and then Pest, early “clinics” were set up for the university in hospitals (for instance, the women’s clinic was founded in 1786, the eye clinic in 1801). In 1848, the independentist government decided to build separate medical clinics, but after the defeat in the war of independence, the question was removed from the agenda. In the 1860s, the issue was again on the agenda. In 1866/67, the Medical Faculty submitted a memorandum to the Council of GeneralGovernor stating what kind of modern institutes and clinics were needed for scientific research.258 The enthusiastic supporter of the issue of clinics, Frigyes Korányi (most significant member of a prestigious doctordynasty), and an architect made a research trip abroad before the plans for the new, so-called medical premises were prepared on a large site near the Faculty. A prosperous time of clinic building came about in the 1870s and was connected to the emergence of different medical departments. The

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shorter, specialised and lower-degree tracks (surgeon, obstetrician, eyedoctors) were finally discontinued in 1875, and specialised departments were founded: medical physics in 1870, pathological histology in 1871, a second department of internal medicine in 1872, paediatrics in 1873, physiological and pathological chemistry in 1873, public hygiene in 1874, a second department of anatomy in 1878, a second department of surgery in 1880, a second department of obstetrics in 1880, etc.259 In this wave of department foundations, psychiatry came late. The Department of Mental Health and Pathology was founded in 1882 only, headed by Károly Laufenauer. Two other related departments followed in a decade: the Department of Forensic Mental Pathology headed by Ern˝ o Moravcsik in 1892 and the Department of Neurology led by Jen˝ o Jendrássik in 1893. Related to department foundations, the energetic project of building modern medical clinics began on the “medical premises” near the Medical Faculty in the 1870s. The building of the first surgery clinic started in 1872–1873, two pathological institutes were established in 1875–1876, two clinics for internal medicine in 1877 and 1879, the second surgery clinic in 1878, with many others to follow in the 1880s and 1890s.260 The first small psychiatric university clinic was set up in 1882 at the Saint Roch Hospital (rather than on the medical premises), and it was subsequently split and moved to other buildings. The head, Károly Laufenauer, found its conditions unacceptable and fought an uphill battle for a modern and separate psychiatric clinic until his death in 1901. This was eventually opened in 1908 on Balassa Street.261 By the 1860s–1870s, anatomical and histological research had come to the fore throughout Europe. The expansion of research schools, teaching hospitals and the increasing availability of scientific equipment made clinical and laboratory experimentation possible and mandatory.262 Germany was leading in what Shorter called “the first biological psychiatry”263 with its numerous research institutes. German biological psychiatry exerted a strong influence in Hungary. From the 1870s, many young Hungarian doctors who would turn into prominent psychiatrists visited such famous centres of brain and histological research as Meynert’s institute in Vienna and Westphal’s in Berlin (as well as Charcot’s ward in the 1880s at the Salpêtrière, where important physiological and neural investigations were conducted). Stimulated by a strong German background, Laufenauer’s department and the attached mental and nerve clinic became the centre of modern research activities in the country.264

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In the rhetoric and “self-image” of psychiatrists in the period, stress was laid on the formation of an “own” psychiatry as part of the larger scheme of nation-building, contributing to the elevation of a “backward” country up to Western standards. Hungarian “national sciences” were thus creatively receptive of Western scholarly paradigms (originating in Austria or Germany, but also in Britain and France) especially from the 1870s. In spite of contemporary nationalist endeavours full of striving for more independence and the creation of autonomous national academe, scholarly practices in the country could not escape the “penetration” of foreign paradigms, the importation of foreign models and—to a large extent—the reproduction of institutional and intellectual achievements of the West.

Notes 1. László Epstein, “Magyarország elmebetegügye” (Mental Health Care in Hungary), Gyógyászat (Medicine) 38 (1897a): 582. 2. Ibid. For similar notions, see Károly Laufenauer, El˝oadások az idegélet világából (Lectures in the World of Nerve-Life) (Budapest: Királyi Magyar Természettudományi Társulat, 1899a), 40–45; Károly Laufenauer, “A hypnotismus és a vele rokon ideges tünemények” (Hypnotism and Related Nervous Phenomena). Természettudományi Közlöny (Natural Scientific News) 178 (1884): 233–250; 179 (1884): 273–286. 3. Karl Wilhelm Ideler (1795–1860) was a German “Romantic” psychiatrist whose psychological approach drew heavily on Romanticism’s metaphysical notion of the inner consciousness. 4. Ern˝ o Moravcsik, “A psychiatria fejl˝ odése hazánkban az utolsó 50 év alatt” (The Development of Psychiatry in Our Country During the Last 50 Years), Orvosi Hetilap (Medical Weekly) 1 (1906a): 38–42. Also see János Lyachovics, “Töredékek a budai magán o ˝rüldéb˝ ol” (Fragments from the Buda Private Madhouse), Orvosi Hetilap (Medical Weekly) 12 (1857): 183–189; 13 (1857): 200– 202; 4 (1858): 54–58; 6 (1858): 85–88. 183–189, 200–202. 5. Moravcsik (1906a), 38. On the troubled relationship between psychiatry and medicine, see also Laufenauer Károly, “Néhány szó a hazai elmekórtani oktatás tárgyában” (A Few Words on Teaching Mental Pathology in Hungary), Orvosi Hetilap (Medical Weekly) 45 (1876): 90; Jakab Salgó, Az elmekórtan

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tankönyve (Textbook of Mental Pathology) (Budapest: Franklin Társulat, 1890), 1–2; Schaffer Károly, “Az elme- és idegkórtannak egymáshoz való viszonya és fejl˝ odése. A constitutio fogalma” (The Relationship of Mental- and Nervous Pathology, and Their Development. The Concept of Constitution), Orvosi Hetilap (Medical Weekly) 7 (1925): 135. 6. Moravcsik (1906a), 39. 7. Several designations were used for the asylum in the observed period. In addition to the original Lipótmez˝ o Royal National Lunatic Asylum, it was often called as Lipótmez˝ o State or Public Lunatic Asylum, or simply as Lipótmez˝ o lunatic asylum in different official documents, psychiatric writings and publications. In the last decades of the nineteenth century, it often appears as Lipótmez˝ o mental asylum or institution. It was officially renamed as Hungarian Royal State Mental Institute in 1897 (see note 3 in Chapter 4). In the rest of the book, I generally use the term found in the relevant documents or simply the “Lipótmez˝ o” designation—as the institution commonly existed in the public mind and was referred to in numerous articles. 8. See, for instance, Epstein (1897a), 598. For a number of reasons, linked to the persistence of rigid feudal structures in matters economic, political, intellectual and other, due largely to paralysing tensions between the imperial state (the Habsburg Monarchy of which Hungary was a part) and a strong historical nobility detaining the quasi-monopoly of landed estates, social authority, local administrative power and entitlement for political representation (together with a number of inherited feudal privileges), the acceleration of the modernisation process in Hungary mostly followed the radical political transformations of the nineteenth century. The Age of Reform (1825–1848) was characterised by the movement lead by the reform minded political and intellectual class recruited in the nobility, aristocracy and, partly, among non-noble “honoratiors” (with advanced education) aware of and committed to West European political, economic and social developments. Their efforts were of very complex nature, strongly marked by romantic nationalism. These included the following main objectives: the fight for “national independence” (including a measure of negotiated or enforced autonomy in or against the

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Habsburg empire); the stress on Magyar political hegemony and symbolic pre-eminence in the would be multi-ethnic nation state (imposition of Hungarian as state language, magyarisation of elite education, etc.); the elimination of feudal social structures (extension of suffrage to commoners, taxation of noble estates, abolition of bondage tying serfs to estates, etc.); the promotion or the introduction of legal reforms proper to Western type societies opening up to laissez-faire capitalism (right of free settlement and enterprise for all, freedom of press and speech, equality of citizens before the law, etc.); and, lastly, the sponsoring of a number of economic, cultural or social innovations extending state competence or mobilising public investments together with private ones in fields hitherto neglected or left over to individual initiatives, as various as public transportation (bridges, railways), control of floods, a credit system, cultural institutions (theatres, museums, academies), etc. Although by far not all of these objectives were translated into reality, developments were indubitable in many areas during the “Reform era.” Following the failure of the 1848–1849 Revolution and War of Independence, political oppression during the neo-absolutist era certainly paralysed most independent political endeavours and hindered to some extent the development of autonomous intellectual initiatives. In the area of public health care, however, some forms of systematic management of public hospitals and health care were initiated by the absolutist imperial court right during the 1850s. Under the Dualist regime after the 1867 political Compromise between Hungary and Imperial Austria (that redefined the constitutional, political and economic relationship between the two parts of the empire until its dissolution at the end of the First World War), a number of measures aimed at the extension of state competence in areas earlier uncontrolled by public powers or left to the responsibility of families, local landlords or communities and above all the churches. These included: education; the care for the poor and sick; the control of prostitution, etc. See: Gábor Gyáni and György Kövér, Magyarország társadalomtörténete a reformkortól a második világháborúig (The Social History of Hungary from the Age of Reform Until WWII)

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(Budapest: Osiris, 2001); Péter Hanák, Magyarország a Monarchiában (Hungary in the Monarchy) (Budapest: Gondolat, 1975); Endre Kovács and László Katus, eds., Magyarország története (The History of Hungary), Vol. 6 (Budapest: Akadémia Kiadó, 1987 [1979]); László Kontler, A History of Hungary (Budapest: Atlantisz Publishing House, 2002). 9. The stress in Oláh’s quote is probably on the non-economical nature of this huge institution; it reveals an appreciation of the state’s enlightened choice of investing in such a medical institution. 10. Gusztáv Oláh, “Emlékezzünk régiekr˝ ol” (Remembering Psychiatrists in the Past). Unpublished manuscript of a lecture given in 1922, 1–15. 11. Gusztáv Zombory, “A lipótmezei országos tébolyda Budán” (The Lipótmez˝ o National Lunatic Asylum in Buda), Hazánk s a Külföld (Our Nation and Foreign Countries) 43 (1867): 679– 680. 679. The royal and magnificent image of Lipótmez˝ o as a “colossal building” decorated with the “Hungarian royal coat of arms” appears in other accounts as well, see, for instance: Vasárnapi Újság (Sunday News), “Látogatás a lipótmezei tébolydában” (Visit to the Lipótmez˝ o Lunatic Asylum). June 13, 1869: 325, 328. 12. Oláh (1922), 1–15. 13. Oláh (1922), 2. 14. Epstein (1897a), 580, 600. 15. For modern and comprehensive historical approaches to European psychiatry, see: Roy Porter, Madness. A Brief History (Oxford: Oxford University Press, 2002); Edward Shorter, A History of Psychiatry from the Era of the Asylum to the Age of Prozac (New York: Wiley, 1997); Henri Ellenberger, The Discovery of the Unconscious: The History and Evolution of Dynamic Psychiatry (New York: Basic Books, 1970); for clinical psychiatry: German Berrios and Roy Porter, eds., A History of Clinical Psychiatry. The Origin and History of Psychiatric Disorders (London: Athlone, 1995); a useful collection of essays: William F. Bynum, Roy Porter and Michael Shepherd, eds., The Anatomy of Madness. Essays in the History of Psychiatry, 3 Vols. (London: Tavistock Publications, 1985).

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16. Porter (2002), 89–92; William Parry-Jones, “The Model of the Geel Lunatic Colony and Its Influence on the NineteenthCentury Asylum System in Britain,” in Madhouses, Mad-Doctors, and Madmen. The Social History of Psychiatry in the Victorian Era, ed. Andrew Scull (London: The Athlone Press, 1981), 201–218; Jonathan Andrews, Asa Briggs, Roy Porter, Penny Tucker and Keir Waddington, The History of Bethlem (London: Routledge, 1997). 17. Shorter (1997), 2–4. 18. Shorter’s account shows a tendency to hail biological psychiatry and its achievements which he regards as scientific and essential in the treatment of mental diseases, hence, scientific psychiatry is better than no psychiatry at all. His appreciation of biological psychiatry also explains his despise for, for instance, the psychoanalytic movement (see his chapter “The Psychoanalytic Hiatus”) as well as some trends in dynamic psychiatry (like the work of Charcot). For a nuanced picture of the manifold meanings of and attitudes to insanity in premodern societies, see Roy Porter, Mind-Forg’d Manacles. A History of Madness in England from the Restoration to the Regency (London: Penguin Books, 1987). 19. Michel Foucault, Madness and Civilization. A History of Insanity in the Age of Reason, trans. Richard Howard (London: Routledge, 1992 [1961]), 38–39. 20. “It constituted one of the answers the 17th century gave to an economic crisis that affected the entire Western world: reduction of wages, unemployment, scarcity of coin,” Foucault (1992), 46, 48–49. 21. See Thomas Szász, see: The Myth of Mental Illness: Foundations of a Theory of Personal Conduct (New York: Dell., 1961); Ronald David Laing, The Divided Self: A Study of Sanity and Madness (London: Tavistock, 1960); Erving Goffman, Asylums (New York: Anchor Books, 1961). 22. For a powerful criticism of this thesis, see Martin Roth and Jerome Kroll, The Reality of Mental Illness (Cambridge: Cambridge University Press, 1986). 23. From Thomas Szász, see: The Manufacture of Madness: A Comparative Study of the Inquisition and the Mental Health Movement (London: Routledge & Kegan Paul, 1971; 1st ed.: New York: Harper & Row, 1970); The Myth of Psychotherapy. Mental

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Healing as Religion, Rhetoric, and Repression (New York: Anchor Press/Doubleday, 1978). 24. As Micale and Porter show in their excellent historiographic chapter, by the end of the 1960s the ideas of these writers “had combined with French and German Marxist psychologies, British anti-psychoanalytic sentiment, critical feminist theory, and the mental patients’ liberation movement in a comprehensive attack on modern mental health institutions and practices. A powerful anti-psychiatry was under way.” See Mark Micale, “Introduction: Reflections on Psychiatry and Its Histories,” in Discovering the History of Psychiatry, ed. Mark Micale and Roy Porter (Oxford: Oxford University Press, 1994), 3–36; esp. 8. See also Shorter’s discussion of the antipsychiatric movement in Shorter (1997), 272–277. 25. For historiographic reviews, apart from the already mentioned Micale and Porter chapter, see: Andrew Scull, “Psychiatry and Its Historians,” History of Psychiatry 2 (1991): 239–250; Andrew Scull, “A Quarter Century of the History of Psychiatry,” Journal of the History of the Behavioral Sciences 3 (1999): 239–246; Andrew Scull, “Psychiatrists and Historical ‘Facts’. Part One, The Historiography of Somatic Treatments,” History of Psychiatry 2 (1995a): 225–241; Andrew Scull, “Psychiatrists and Historical ‘Facts’. Part Two, Re-writing the History of Asylumdom,” History of Psychiatry 3 (1995b): 387–394. 26. Mostly in the Foucauldian spirit, these works set out to identify different national models in the history of European psychiatry by more systematic and objective analysis. See especially, on the German, French and English cases: Klaus Doerner’s Bürger und Irre first published by Europäische Verlagsanstalt in 1969, in English: Madman and the Bourgeoisie. A Social History of Insanity and Psychiatry, trans. J. Neugroschel and J. Steinberg (Oxford: Basil Blackwell, 1981); on the French case: Robert Castel, L’Ordre psychiatrique: L’Age d’or de l’aliénisme first published in Paris by Minuit in 1976, translated as The Regulation of Madness: Origins of Incarceration in France (Berkeley: University of California Press, 1988); Francoise and Robert Castel and Anne Lovell, The Psychiatric Society (New York: Columbia University Press, 1981); on the English case: Andrew Scull, Museums of Madness: The Social Organization of

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Insanity in Nineteenth-Century England (London: Allen Lane, 1979). 27. For more recent criticism on Foucault, see Arthur Still and Irving Velody, eds., Rewriting the History of Madness. Studies in Foucault’s ‘Histoire de la Folie’ (London and New York: Routledge, 1992). For early critical French reception of Foucault’s book, see Georges Canguilhem’s report on Foucault’s “Folie et déraison,” published as “Annexe 2” in Didier Eribon, Michel Foucault (1926–1984) (Paris: Flammarion, 1991) 358–361. Canguilhem’s text is dated 1960. See also criticism by Henri Gouhier, Daniel Lagache, and Fernand Braudel quoted by Eribon (1991), 138–144. 28. Psychiatric history writing has produced a rich and manifold literature during the last decades. For a few important comprehensive works on different Western national psychiatries, see: on French psychiatry Ian Dowbiggin, Inheriting Madness: Professionalization and Psychiatric Knowledge in Nineteenth-Century France (Berkeley: University of California Press, 1991) and Jan Goldstein, Console and Classify: the French Psychiatric Profession in the Nineteenth Century (Cambridge: Cambridge University Press, 1987); on German psychiatry, see works by Otto Marx (quoted below); Eric J. Engstrom, Clinical Psychiatry in Imperial Germany. A History of Psychiatric Practice (Ithaca: Cornell University Press, 2003); Anne Goldberg, Sex, Religion, and the Making of Modern Madness: The Eberbach Asylum and Germany Society, 1815–1849 (New York: Oxford University Press, 1999); on English psychiatry: Porter (1987); Andrew Scull, The Most Solitary of Afflictions: Madness and Society in Britain, 1700–1900 (New Haven: Yale University Press, 1993); Janet Oppenheim, “Shattered Nerves.” Doctors, Patients, and Depression in Victorian England (New York, Oxford: Oxford University Press, 1991). From the extensively growing literature on women and madness, see: Elaine Showalter, The Female Malady: Women, Madness, and English Culture, 1830–1980 (London: Virago, 1985); Yannick Ripa, Women and Madness: The Incarceration of Women in Nineteenth-Century France (Minneapolis: University of Minnesota Press, 1991); Phyllis Chesler, Women and Madness (New York: Doubleday and Co., 1972). 29. See Porter (1987), 1–33.

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30. Chief French cities built such receptacles, but elsewhere it was less characteristic, and even in France, the number of insane locked away was small. 31. The Act first authorising the setting up of public lunatic asylums was passed in 1808; the provision of public asylums only became mandatory after 1845. See Porter (1987), 7–9. 32. Shorter (1997), 5. 33. Porter (2002), 97. 34. Shorter (1997), 5. 35. Porter (1987), 8–9. 36. Porter (1987), 136–148 and Porter (2002), 95. 37. See William Parry-Jones, The Trade in Lunacy. A Study of Private Madhouses in the Eighteenth and Nineteenth Centuries (London: Routledge and Kegan Paul, 1971). On madhouses and mad-doctors, see also Andrew Scull, Charlotte MacKenzie and Nicholas Hervey, Masters of Bedlam. The Transformation of the Mad-Doctoring Trade (Princeton: Princeton University Press, 1996). 38. For the argument that such cruelty exhibited at asylums should not only be seen in terms of the interpretations of later reformers but also in the context of contemporary social practices and the ubiquitous use of, for instance, whipping in the home and at the workplace, see Andrew Scull, “Moral Treatment Reconsidered,” in Madhouses, Mad-Doctors and Madmen. The Social History of Psychiatry in the Victorian Era, ed. Andrew Scull (London: The Athlone Press, 1981), 106–107, and Porter (1987), 285. 39. See below. 40. For Shorter’s numbers, see Shorter (1997), 6. 41. Shorter concludes that “in France, Foucault’s elect terrain with its almost thirty million people, it is absurd to insist on any kind of grand confinement.” Shorter (1997), 6. 42. Shorter (1997), 6–7. 43. See Erna Lesky, The Vienna Medical School of the 19th Century, trans. L. Williams and I.S. Levij (Baltimore and London: Johns Hopkins University Press, 1976), 149. (Original German title: Die Wiener Medizinische Schule im 19. Jahrhundert, published in 1965.) 44. György Gortvay, Az újabbkori magyar orvosi m˝ uvel˝odés és egészségügy története (The History of Hungarian Medical Culture

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and Health Care in Modern Times) (Budapest: Akadémia Kiadó, 1953), 132; for data on Austrian institutions, see Kálmán Pándy, Gondoskodás az elmebetegekr˝ol más államokban és nálunk (The Care for Mental Patients Abroad and in Our Country) (Gyula: Corvina, 1905), 283–320. 45. Lesky (1976), 150. 46. The crucial work is William Battie’s A Treatise on Madness (London: Whiston, 1758). See Shorter (1997), 8–10. 47. On Chiarugi, see Porter (2002), 104, 130–131; and Shorter (1997), 9–14, 27–36. 48. The story of his dramatic gesture of striking the chains off his patients is a myth in historiography, for its deconstruction, see Dora B. Weiner, “‘Le Geste de Pinel’: The History of a Psychiatric Myth,” in Discovering the History of Psychiatry, ed. Mark Micale and Roy Porter (Oxford: Oxford University Press, 1994), 232– 248. 49. For one of the best discussions on Pinel, see Goldstein (1987), esp. 64–128. Also see Castel (1988), and the chapter “The Revolution and the Emancipation of the Insane” by Doerner (1981), 119–139. 50. See Bynum (1981), 35–57. 51. For shifts in the portrayal of the insane and the attached meanings and values, see the chapter “Fools and Folly” in Porter (2002), 62–89, and Scull (1981), 105–121. 52. For Esquirol, see Goldstein (1987). 53. On moral therapy and therapeutic asylums in England, see Ida Macalpine and Richard Hunter, George III and the MadBusiness (London: Allen Lane, 1969); Anne Digby, Madness, Morality, and Medicine: A Study of the York Retreat, 1796– 1914 (Cambridge and New York: Cambridge University Press, 1985); Scull, MacKenzie and Hervey (1996); Richard Hunter and Ida Macalpine, Psychiatry for the Poor, 1851. Colney Hatch Asylum, Friern Hospital. A Medical and Social History (London: Dawsons, 1974); Charlotte MacKenzie, Psychiatry for the Rich. A History of Ticehurst Private Asylum, 1792–1917 (London and New York: Routledge, 1993). 54. The classic work on the York Retreat is: Digby (1985). 55. See Porter (1987), 222–226. 56. Bynum (1981), 42–44.

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57. See Ibid., 42–43; Digby (1985). 58. Bynum (1981), 51. 59. Ibid., 51–52. For French wars between early psychiatrists and the Catholic orders over the treatment of psychological disorders, between somatically oriented psychiatrists and psychologically oriented academic philosophers (spiritualist school of philosophy), see Dowbiggin (1985), 11–76. 60. Lesky (1976), 5–6. 61. See Roger Cooter, “Phrenology and British Alienists, ca. 1825– 1845,” in Madhouses, Mad-Doctors, and Madmen. The Social History of Psychiatry in the Victorian Era, ed. Andrew Scull (London: The Athlone Press, 1981), 60, 58–104; also by Cooter, The Cultural Meaning of Popular Science. Phrenology and the Organization of Consent in Nineteenth-Century Britain (Cambridge and New York: Cambridge University Press, 1984). 62. Cooter (1981), 77. 63. Ibid., 81. 64. Lesky (1976), 150. 65. Ibid., 150–151. 66. For no-restraint, see Chapter 3. On the questions of restraint and seclusion at Hanwell and Lincoln asylums as well as Conolly as a proponent of seclusion, see: Leslie Topp, “Single Rooms, Seclusion and the Non-restraint Movement in Britain, 1838–1844,” Social History of Medicine 31, no. 4 (2018), 754–773. On a more general history of the use of single rooms or cells, see: Leslie Topp, “Isolation, Privacy, Control and Privilege: Psychiatric Architecture and the Single Room,” in Healing Spaces, Modern Architecture, and the Body, ed. Sarah Schrank and Didem Ekici (London and New York: Routledge, 2016), 85–102. 67. See Gortvay (1953), 132. 68. Lesky (1976), 151. 69. On these institutions, see Leslie Topp, Freedom and the Cage. Modern Architecture and Psychiatry in Central Europe, 1890– 1914 (Pennsylvania: The Pennsylvania State University Press, 2017). 70. For more complex accounts of the forces behind institutionalisation, see Peter Bartlett, The Poor Law of Lunacy: Administration of Pauper Lunatics in Nineteenth-Century England (London: Cassell Academic, 1998); Peter Bartlett and David Wright, eds.,

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Outside the Walls of the Asylum. The History of Care in the Community (London and New Brunswick, NJ: Athlone Press, 1999); Joseph Melling and Bill Forsythe, eds., Insanity, Institutions and Society. New Research in the Social History of Madness, 1800–1914 (London: Routledge, 1999); Kathleen Jones, Asylums and After: A Revised History of Mental Health Services, from the Early 18th Century to the 1990s (London: Athlone, 1993). 71. For the different national models of health care provision, see Roy Porter, The Greatest Benefit to Mankind. A Medical History of Humanity from Antiquity to the Present (London: HarperCollins, 1997), 348–428; Shorter (1997), 35. 72. See Porter (1997), 405. 73. See Shorter (1997), 35; for state medicine and the notion of the medical police in Austria, see Lesky (1976), 86–96 and 248–261. I discuss the Austrian case in more details below. 74. See Shorter (1997), 35–36; the chapters “Nineteenth-Century Medical Care” and “Public Medicine” in Porter (1997), 348– 428. 75. Porter describes the rise of new pessimism concerning asylums during the last third of the nineteenth century, Shorter dates it by 1900. See Porter (2002), 118, 89–123; Shorter (1997), 46–48, 33–69. 76. See discussed in more details in Chapter 4. 77. See the chapter “Scientific Medicine in the Nineteenth Century” in Porter (1997), 304–348; and William F. Bynum, Science and the Practice of Medicine in the Nineteenth Century (Cambridge: Cambridge University Press, 1994). 78. See Porter (1997), 304–348 and Bynum (1994). 79. These significant changes in Viennese medical culture are discussed in detail below. See Lesky (1976), 1–248. 80. See the chapter “Scientific Medicine in the Nineteenth Century” in Porter (1997), 304–348 and Bynum (1994). 81. See more discussion on Rokitanski in Chapters 3 and 4. 82. For the psychiatric culture at Illenau, see Cheryce Kramer, A Fools’ Paradise. The Psychiatry of Gemüth in a Biedermeier Asylum (Doctoral dissertation, The University of Chicago, 1998). 83. Heinroth and Karl Ideler were representatives of “Romantic psychiatry,” the psychological approach to insanity characterised by speculative metaphysics. For Romantic psychiatry, see Otto

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Marx, “German Romantic Psychiatry,” History of Psychiatry 4 (1990): 351–380; 1 (1991): 1–26. 84. See Engstrom (2003); Otto Marx, “Wilhelm Griesinger and the History of Psychiatry: A Reassessment,” Bulletin of the History of Medicine 46 (1972): 519–544. See discussed in detail in Chapter 5. 85. See Otto Marx, “Nineteenth Century Medical Psychology. Theoretical Problems in the Work of Griesinger, Meynert and Wernicke,” Isis 61 (1970): 355–370; Shorter (1997), 76–81. 86. See Porter (2002), 118–122; Shorter (1997), 46–68. Lesky claims that an 1845 speech by the Austrian Joseph Dietl in which he expressed his gloomy views on the existing therapy is recorded in the history of medicine as “the program of therapeutic nihilism,” see Lesky (1976), 122. 87. On the medical concept as well as rich social meanings of degeneration, see Daniel Pick, Faces of Degeneration: A European Disorder, c.1848–c.1918 (Cambridge: Cambridge University Press, 1989); the essays in J. Edward Chamberlin and Sander L. Gilman, eds., Degeneration: The Dark Side of Progress (New York: Columbia University Press, 1985); Robert Nye, Crime, Madness, and Politics in Modern France: The Medical Concept of National Decline (Princeton, NJ: Princeton University Press, 1984); William F. Bynum, “Alcoholism and Degeneration in nineteenth Century European Medicine and Psychiatry,” British Journal of Addiction, 79 (1984): 59–70. 88. Epstein (1897a), 580. 89. Research is especially needed into the different circumstances in rural regions and town communities; the role of the parish and boroughs; family attitudes to madness as well as the condition of insane people in custody (in prisons and workhouses). 90. See it discussed in details below. 91. Gortvay (1953), 57–58; Gyula Magyary-Kossa, “Régi magyar gyógyszerészekr˝ ol és gyógyszertárakról” (On Old Hungarian Apothecaries and Pharmacies), in Magyar orvosi emlékek. Értekezések a magyar orvostörténelem köréb˝ol (Hungarian Medical Sources. Studies in Hungarian Medical History), Vol. 2 (Budapest: Magyar Orvosi Könyvkiadó Társulat, 1940h), 73–103. On folk medicine in Hungary, see: Mihály Hoppál and László Törö, “Népi gyógyítás Magyarországon” (Folk Healing in Hungary),

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Az Országos Orvostörténeti Könyvtár Közleményei (Publications of the National Library for the History of Medicine) Supplement 7–8 (1975): 15–63; Éva Pócs, “A népi gyógyászat és a néphit kutatásának határterületei” (The Borderland Areas in the Research on Folk Healing and Folk Belief), Az Országos Orvostörténeti Könyvtár Közleményei (Publications of the National Library for the History of Medicine) Supplement 11–12 (1979): 61–75; József Spielmann, “Történelmi reflexiók a népi orvoslás és az orvostudomány viszonyáról” (Historical Reflections on the Relationship Between Folk Healing and Medicine), Az Országos Orvostörténeti Könyvtár Közleményei (Publications of the National Library for the History of Medicine) Supplement 11–12 (1979): 35–50. 92. Sometimes also translated to “Locotenential Council” in historiography. 93. For the widespread practice of unorthodox healers, see Gortvay (1953), 61–63; Magyary-Kossa, “Az olejkárok” (Wandering Herbalists), in Magyar orvosi emlékek. Értekezések a magyar orvostörténelem köréb˝ol (Hungarian Medical Sources. Studies in Hungarian Medical History), Vol. 2 (Budapest: Magyar Orvosi Könyvkiadó Társulat, 1940g), 162–171, and more recently, Lilla Krász: Quackery Versus Professionalism? Characters, Places and Media of Medical Knowledge in EighteenthCentury Hungary,” Studies in History and Philosophy of Biological and Biomedical Sciences 43 (2012) 700–709, more specifically on monastery pharmacies: Katalin Pataki, “Healers, Quacks, Professionals: Monastery Pharmacies in the Rural Medical Marketplace Society and Politics 12, no. 1 (2018): 32–49. http://socpol. uvvg.ro/docs/2018-1/03.Katalin_Pataki.pdf. See also András Kelemen, “A sámánisztikus tevékenység kórlélektani vizsgálata” (The Psycho-Pathological Study of Samanistic Activity), Az Országos Orvostörténeti Könyvtár Közleményei (Publications of the National Library for the History of Medicine) Supplement 11– 12 (1979): 78–87; Balázs Bugyi, “Népi gyógyászat a reformkori orvostudori értekezésekben” (Folk Medicine in Doctoral Treatises in the Age of Reforms), Az Országos Orvostörténeti Könyvtár Közleményei (Publications of the National Library for the History of Medicine) Supplement 11–12 (1979): 313–323; Mihály Szilágyi, “A boszorkányperek orvostörténelmi háttere

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Tolna megye Duna menti községeiben” (The Medical History Background of Witch Trials in Communities by the Danube in Tolna County), Az Országos Orvostörténeti Könyvtár Közleményei (Publications of the National Library for the History of Medicine) 105–106 (1984): 61–74. 94. Magyary-Kossa, “Orvosi gyakorlat a régi Magyarországon” (Medical Practice in Old Hungary), in Magyar orvosi emlékek. Értekezések a magyar orvostörténelem köréb˝ol (Hungarian Medical Sources. Studies in Hungarian Medical History), Vol. 1 (Budapest: Magyar Orvosi Könyvkiadó Társulat, 1940d), 69–119. 95. István Zsakó, “Egy elmebeteg ügyében történt leiratok és jelentések a XVIII. században (Adattár)” (Ordinances and Reports in the Case of a Mental Patient in the 18th Century. Collection of Data), Az Országos Orvostörténeti Könyvtár Közleményei (Publications of the National Library for the History of Medicine) 37 (1965b): 291–292. My account is based on Zsakó’s Hungarian translation of the sources. 96. Ibid., 291–92. 97. Matthias Hunyadi, king of Hungary between 1440 and 1490. 98. Zsakó (1965b), 291–292. 99. For healing Catholic Orders in the Hungarian Kingdom from the Middle Ages, see: Gortvay (1953), 45, 56, 114, 131; István Czagány, “A budai orvosok és gyógyszerészek a feudalizmus korában” (Buda Doctors and Pharmacists in the Time of Feudalism), Az Országos Orvostörténeti Könyvtár Közleményei (Publications of the National Library for the History of Medicine) 71–72 (1974): 71–94. For primary sources, see: Gyula MagyaryKossa, Értekezések a magyar orvostörténelem köréb˝ol (Hungarian Medical Sources. Studies in Hungarian Medical History), Vols. 3– 4 (Budapest: Magyar Orvosi Könyvkiadó Társulat, 1940a). More recently, see Katalin Pataki: “Medical Provision in the Convents of Poor Clares in Late-Eighteenth-Century Hungary. Cornova,” ˇ Revue Ceské spoleˇcnosti pro výzkum 18. století 6, no. 2 (2016): 33–58. 100. See Gortvay (1953), 126; János Antal, “Az irgalmasrend kórházai” (The Hospitals of the Hospitaller Order), Népegészségügy (Public Healthcare), 10, no. 7–8 (1929): 395–397, 466–468; Magyary-Kossa (1940a), 46, 120, 220.

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101. See discussion of the importance of the Eger Scola Medicinalis in the section on medical training in this chapter. 102. I am aware that the term “patient material” has inhuman connotations. However, I often use the term in the book (from now on, without quotation marks) precisely to denote the sort of medical attitude towards patients that characterised certain trends in clinical and academic medicine interested in phenomena deducible from the observation of a big number of patients in larger institutions in the second part of the nineteenth century. 103. For religious medical institutions and hospitals of the Hospitaller Order in the nineteenth century, see László Sasvári, “A magyarországi egyházi betegellátó intézetek és testületek a XIX. század második felében” (Hungarian Religious Medical Institutes and Bodies in the Second Part of the Nineteenth Century), Az Országos Orvostörténeti Könyvtár Közleményei (Publications of the National Library for the History of Medicine) 113– 114 (1986b): 122–128; Sasvári, “A magyarországi betegápoló irgalmas rend m˝ uködése (1867–1918)” (The Caring Activity of the Hungarian Hospitaller Order, 1867–1918), Az Országos Orvostörténeti Könyvtár Közleményei (Publications of the National Library for the History of Medicine) 115–116 (1986a): 125–137. 104. Here I heavily rely on Béla Ringelhann and Imre Soós, “Az Egri Megyei Kórház el˝ odeinek vázlatos története, 1726–1950” (The Outline of the History of the Eger County Hospital and Its Former Institutions, 1726–1950), in Emlékkönyv az Egri Megyei Kórház fennállásának 10. Évfordulójára (Memorial Volume Published on the Occasion of the Eger County Hospital’s Tenth Anniversary), ed. Béla Ringelhann (Eger: A Heves Megyei Tanács Kórházának közleményei, 1960), 2– 51; Béla Ringelhann and Imre Soós, “Adatok az egri orvosi iskoláról, kezdeményez˝ ojének és tanárának, Markhót Ferencnek m˝ uködésér˝ ol” (Data on the Eger Medical School and on the Work of Its Founder and Teacher, Ferenc Markhót), Az Országos Orvostörténeti Könyvtár Közleményei (Publications of the National Library for the History of Medicine) 27 (1963): 129–138. 105. Ringelhann and Soós (1960), 21, 7. 106. Ibid., 7, 14. 107. The Hungarian branch of the Hospitaller Order belonged to the common Austrian-Hungarian province until 1856, when the

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separate Hungarian Order was formed. In 1903 the order had 13 convents and hospitals in the country. 108. Ringelhann and Soós (1960), 21. 109. Ibid., 17. 110. The story from Historia Domus is recounted in Ringelhann and Soós (1963), 133–134. 111. Ringelhann and Soós (1960), 17. 112. Ibid., 21–22. 113. Ibid., 22. 114. In 1868, 17 mental patients were treated simultaneously. While in 1871 there were 28 beds for somatic patients and 20 for mental patients, in 1878 their ratio was 28–26, and by 1894: 32–80. See ibid., 24–27. 115. From the 1860s, the Buda Hospital of the Hospitaller Order also gained importance. In 1861, the Buda Hospitaller Order refurbished an old building with 170 beds for insane patients across from the Hospital. See: Klára Brüll Engländer, Orvosok és kórházak Pest-Budán (Doctors and Hospitals in Pest-Buda) (Budapest, 1930), 93. 116. The number of available beds in mental institutions at the end of the nineteenth century amounted to approximately 6,000, see discussion below. 117. Many sources testify to this function of the institute by the end of the period. Numerous case histories at Lipótmez˝ o Royal Lunatic Asylum demonstrate that incurable patients were sent to Eger to ease overcrowding at Lipótmez˝ o, which was not supposed to treat incurables. See, for instance, Ministry of Interior, Magyarország elmebetegügye az 1900. évben (Mental Health Care in Hungary in 1900) (Budapest: Schmidl Sándor Könyvnyomdája, 1901). 118. Lipót Grósz, Emlékirat a hazai betegápolási ügy keletkezése, fejl˝odése, s jelenlegi állásáról (Memoir Concerning the Birth, Development, and Present State of Our National Patient Care) (Buda: Magyar Királyi Egyetemi Nyomda, 1869), 10–11. 119. For my translation of the term község, see footnote 211. 120. Grósz (1869), 3. 121. The date 1812 is given by Pándy (1905), 364, whereas Grósz gives 1816. 122. Grósz (1869), 10–11. 123. Ibid.

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124. No. 22,999 writ issued on 22 October 1852, see ibid., 15. 125. No. 7,511 ordinance issued on 4 April 1854, see ibid., 15. 126. No. 6,382 ordinance issued on 6 March 1855, see ibid., 16–19. 127. Ibid., 80–87. 128. No. 26,641 resolution issued by the K.u.K. Ministry of Interior on 4 December 1856. See ibid., 16–38. 129. See Gyáni and Kövér (2001), 372. 130. Further developments in public health care in Dualist period are discussed below. 131. See: Magyary-Kossa, “Az orvos helyzete a régi magyar társadalomban” (The Doctor’s Position in Old Hungarian Society), in Magyar orvosi emlékek. Értekezések a magyar orvostörténelem köréb˝ol (Hungarian Medical Sources. Studies in Hungarian Medical History), Vol. 1 (Budapest: Magyar Orvosi Könyvkiadó Társulat, 1940c), 59–69; Magyary-Kossa, “Régi magyar sebészekr˝ ol” (On Old Hungarian Surgeons), in Magyar orvosi emlékek. Értekezések a magyar orvostörténelem köréb˝ol (Hungarian Medical Sources. Studies in Hungarian Medical History), Vol. 2 (Budapest: Magyar Orvosi Könyvkiadó Társulat, 1940i), 49–66. 132. Gortvay (1953), 66. 133. See Ringelhann and Soós (1960), 16. 134. Gortvay (1953), 66. Gortvay emphasizes that the geographic distribution of doctors was still very uneven. For example, in Csongrád county in 1800, there was only one doctor. In 1840, altogether 9 doctors and 15 surgeons were active in Komárom county, which means that there was one doctor for 15,971 people and one surgeon for 9,583 people. The situation was better in Pest, Buda and Old Buda. See also: Pál Bugát and Ferenc Flór, eds., Magyarországi Orvosrend Névsora 1840-re (Schematismus ordinis medicorum Hungariae) (Name List of the Hungarian Medical Order in 1840) (Pest: Trattner Károly, 1840). 135. This is discussed below. 136. These numbers are added up based on Lipót Grósz’s 1869 list of hospitals and poorhouses, their foundation dates and numbers of beds. See Grósz (1869), 4–7. For Pest and Buda, see also Gyula Magyary-Kossa, “Vázlatok a pest-budai kórházak múltjából” (From the History of Hospitals in Pest-Buda), in Magyar orvosi emlékek. Értekezések a magyar orvostörténelem köréb˝ol (Hungarian

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Medical Sources. Studies in Hungarian Medical History), Vol. 2 (Budapest: Magyar Orvosi Könyvkiadó Társulat, 1940f), 200– 207. 137. See Grósz (1869), 4–7, and Magyary-Kossa (1940f), 200–207. 138. These numbers are provided by György Szabad, “Az önkényuralom kora (1849–1867)” (The Age of Neo-Absolutism, 1849– 1867), in Magyarország története (The History of Hungary), Vol. 6/1, ed. Endre Kovács and László Katus (Budapest: Akadémia Kiadó, 1987 [1979]), 618. 139. Such cells or rooms were separated in hospitals in Arad, Gyöngyös, Kaposvár, Miskolc, Nagyvárad, Nyitra, Szekszárd and Székesfehérvár. There were insane patients in the Buda Hospital of the Hospitaller Order in four rooms, as well as in the Buda town hospital. See Gortvay (1953), 133, and Engländer (1930), 93. For the custody of mental patients in public hospitals, also see Pándy (1905). 140. The letter is presented in István Zsakó, “Az egykori Országos Tébolyda keletkezésének története” (The History of the Establishment of the National Lunatic Asylum), Az Országos Orvostörténeti Könyvtár Közleményei (Publications of the National Library for the History of Medicine) 4 (1956): 87. 141. See Zsakó (1956), 85–87. 142. These numbers are calculated from a chart prepared by Grósz (1869), 94–110. The Royal national public hospital of Pozsony (built between 1857 and 1863) was equipped with 60 beds for mental patients. See Grósz (1869), 114. 143. “Szerkeszt˝ oségi” (Editorial), Gyógyászat (Medicine) 10 (1861): 214. 144. Károly Bolyó, “A tébolydák a jelen korban és ezek m˝ uködése” (Contemporary Lunatic Asylums and Their Operation), Vasárnapi Újság (Sunday Paper) 51 (1862b): 606–607; Pándy (1905), 364; Ministry of Interior (1901), 1. 145. The data in the following two paragraphs recur in many accounts around 1900. See Epstein (1897a), 580–583; Ministry of Interior (1901); István Thewrewk, “Magyarország elmebetegügye” (Mental Health Care in Hungary), Vasárnapi Újság (Sunday Paper) 44 (October 30, 1904): 745–752; Pándy (1905). In his article, Zsakó provides many of these and other findings from results of his systematic investigations including at the National

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Archives in Budapest between 1834 and 1842, see Zsakó (1956), 84–107. 146. Further studies will have to recover the early history of lunatics’ confinement in non-psychiatric institutions in the Hungarian Kingdom. 147. See Epstein (1897a), 580–583; Ministry of Interior (1901); Thewrewk (1904), 745–752; Pándy (1905); Zsakó (1956), 84– 107. 148. Epstein (1897a), 582. 149. See József Pólya, Tudnivalók a Pesten felállított privát Elmekórintézetr˝ol (Information on the Private Mental Asylum Opened in Pest) (Pest: Házinyomda, 1842); Joseph Pólya, Bemerkungen und Statuten der zu Pesth errichteten Privat-Heilanstalt für Gemüths- und Geisteskranke (Pesth: Landerer und Heckenast, ˝ 1844); “Orjintézet Pesten” (Madhouse in Pest), Nemzeti Újság ˝ (National Paper) 1841: 197; Pál Bugát, “Orjintézet Pesten” (Madhouse in Pest), Orvosi Tár (Medical Collections) (1841): 399; Tamás Kun, “A pesti magán-elmekórgyógyintézetnek s eddigi m˝ uködésének rövid ismertetése” (Brief Account on the Pest Private Mental Asylum and Its Operation), Hírnök (Herald) 6 (1844): 34. Pólya could not maintain his asylum due to its high costs. See: Lajos Nagy, Budapest története (The History of Budapest), Vol. III, ed. Domokos Kosáry (Budapest: Akadémiai Kiadó, 1975), 419, and Gortvay (1953), 133–134. 150. See details in Chapter 6. 151. Numerous sanatorium advertisements simply state that no mental patients are admitted, see, for instance, Imre Gúthi, ed., F˝ovárosi almanach, lexikon és útmutató. 1910–1912 (Yearbook, Lexicon and Guide to the Capital, 1910–1912) (Budapest: Légrády testvérek, 1912), 150–157. 152. On the flourishing culture of nerve-clinics, sanatoriums and spas in Europe, see the chapter “Nerves” in Shorter (1997), 113–145. 153. For a discussion of Schwartzer’s asylum see Chapter 3. 154. Porter (2002), 120. 155. János Fekete, “Intézetünk megalapítása, és m˝ uködése 1900-ig” (The Foundation of Our Institute and Its History Until 1900), in Az Országos Ideg- és Elmegyógyintézet 100 éve (Hundred Year Anniversary of the National Institute for Nervous and Mental Diseases), ed. Zoltán Szabó, Zoltán Böszörményi and Mária

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Kuntner (Budapest: Országos Ideg- és Elmegyógyintézet, 1968), 67–83. 69. 156. The German name of Lipótmez˝ o is Leopoldfeld. The detailed discussion of Lipótmez˝ o Royal National Asylum sees in Chapter 4. 157. Sources suggest that some form of medical training was undertaken by medieval universities in the country, especially in the fourteenth and fifteenth centuries. None of them survived for long, thus early medical training largely disappeared in the country by the sixteenth century. For medieval medical training and universities, see: See János Rigó, ed.,A Budapesti Orvostudományi Egyetem jubileumi évkönyve (The Jubilee Yearbook of the Budapest Medical University) (Budapest: Kossuth Nyomda, 1969), 8; Gortvay (1953), 73; Magyary-Kossa, “Orvosi szakoktatás és egyetemi élet a régi Magyarországon” (Medical Training and University Life in Old Hungary), in Magyar orvosi emlékek. Értekezések a magyar orvostörténelem köréb˝ol (Hungarian Medical Sources. Studies in Hungarian Medical History), Vol. 1 (Budapest: Magyar Orvosi Könyvkiadó Társulat, 1940b), 1–59. 158. See the classic history of the Viennese medical school by Lesky (1976). 159. For the history of the Hungarian Medical Faculty, see Rigó (1969); Endre H˝ ogyes, ed., Emlékkönyv a Budapesti Királyi Magyar Tudományegyetem Orvosi Karának múltjáról és jelenér˝ol (‘Memorial Book’ on the Past and Present of the Medical Faculty of the Royal Budapest Hungarian University) (Budapest: Athenaeum, 1896); Tibor Gy˝ ori Nádudvari, Az Orvostudományi Kar története, 1770–1935 (The History of the Medical Faculty, 1770–1935) (Budapest: Egyetemi Nyomda, 1936). 160. János Dániel Perliczy (Perlitzi) had already appealed to Maria Theresa in 1751, requesting the establishment of an institution for medical training in Pest or Nagyszombat, separate from the Nagyszombat Jesuit University. The royal answer was long postponed. On this and the fate of the Eger Scola Medicinalis, see: Gortvay (1953), 74–76; Rigó (1969), 8–9; Ringelhann and Soós (1960), 17. 161. Markhot kept teaching surgeons and midwives for years afterwards, using the Eger hospital for patient presentation. Rigó (1969), 9; Ringelhann and Soós (1960), 17.

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162. For the history of the Hungarian Medical Faculty in relation to the University of Vienna, I used: H˝ ogyes (1896); Rigó (1969); Nádudvari (1936); Lesky (1976); and Gortvay (1953), 73–80. 163. My calculation is based on a table provided by H˝ ogyes (1896), 123. 164. I end with 1850 since László Szögi’s book supplies data on the number of Hungarian medical students at the Viennese Faculty only until 1850. See László Szögi, Magyarországi diákok a Habsburg Birodalom egyetemein. I. 1790–1850 (Hungarian Students Studying at Universities in the Habsburg Empire) (BudapestSzeged, 1994). 165. The data is from Viktor Karády, “A kolozsvári egyetem medikusai a magyar orvosi piacon (1872–1918)” (Medical Students of the Kolozsvár University in the Hungarian Medical Market), Educatio 2 (2002): 237–252. 166. These reforms took place in 1774, 1786, 1807, 1810, 1833, 1848 and 1851. At the opening, the 1749 Viennese curriculum was introduced; in 1774, its newly reformed version. It copiously defined the separate tracks and courses for doctors and “surgeonmasters.” Admission for the more sophisticated doctoral training lasting for five years necessitated previous studies in philosophy. Anatomy, chemistry, botany, physiology, general pathology and pharmacology were taught with clinical practice in surgery, obstetrics and hospital visits. Examinations for the doctoral degree included a theoretical exam, patient treatment and a public disputatio on the thesis. Doctors and surgeons could take additional training that resulted in diploma in eye-doctoring and obstetrics. See H˝ ogyes (1896), 14–15, and Gortvay (1953), 77. 167. After 1786/1787, the unified curriculum was meant to include subjects necessary for both doctoral and surgical practice. The following subjects were taught: anatomy; chemistry; botaniy; historia naturalis; chirurgia generalis et specialis; physiology with anatomy; the study of bandaging and the use of surgical tools; obstetrics; general pathology; pharmacology; medical, surgical and obstetrical practice; and hospital visits. See H˝ ogyes (1896), and Lesky (1976), 1–4, 16–86. 168. In Vienna, in 1804. 169. In 1813 (1810 in Vienna), further reforms followed, valid until 1851, that meticulously defined medical studies in each medical

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field. In 1833, more emphasis was laid on ophthalmology. See H˝ ogyes (1896) and Lesky (1976), 16–86. 170. From 1800, there were several attempts to terminate training resulting in inferior diplomas and only grant universal doctoral degrees. It was, however, not implemented (until 1875) since surgeons were greatly needed in the country. 171. From 1770 to 1848, only a number of centrally defined and authorised textbooks could be used in teaching. From 1850, teachers could freely choose their teaching material and students freely study from additional materials for their exam preparation. See H˝ ogyes (1896), 23, for the list of compulsory teaching material: 116–118; Lesky (1976), 96–106. 172. See H˝ ogyes (1896), 17. 173. The demonstrator system introduced in 1777 also improved teaching conditions. See ibid., 20–22. 174. See ibid., 14–15. There were several subsequent attempts to undo this decision which favoured the Viennese diploma. For instance, in October 1846, the University Council requested that doctors graduated in Pest be allowed to work in Vienna without special exams, otherwise Viennese graduates should also validate their diploma in Pest. All these were denied. See Nádudvari (1936), 457. 175. Nádudvari (1936). H˝ ogyes adds that the faculty’s request was also very modest: they asked for only four-four beds for male and female general patients, four beds for labouring women, and four-four beds for convalescing patients. H˝ ogyes (1896), 19–22. 176. In 1830, the Faculty’s institutes included: the Natural History collection (minerals, animals; 3 rooms); the Chemistry laboratory (an auditorium and a conservatorium); Theatrum anatomicum (3 rooms and 2 kitchen); Anatomical Museum (4 rooms; it contained the remarkable and rich collection of wax anatomical bodies ordered by Joseph II from the Florentine Fontana, which was donated to the faculty in 1789); and five clinics (altogether 11 rooms with 60 beds). The botanical garden was separate. See H˝ ogyes (1896), 22. In 1858, the surgery and obstetrics clinics were moved to new buildings, and further rooms were provided for physiology and zoology. 177. See Gortvay (1953), 81; Domokos Kosáry, M˝ uvel˝odés a XVIII. századi Magyarországon (Culture in 18th-Century Hungary)

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(Budapest: Akadémiai Kiadó, 1996), 250–712, esp. 571– 629; Mihály Szegedy-Maszák, “A polgári társadalom korának m˝ uvel˝ odése, a XVIII. század végét˝ ol 1920-ig” (The Culture of Bourgeois Society from the End of the 18th Century to 1920), in Magyar M˝ uvel˝odéstörténet (The History of Hungarian Culture), ed. László Kósa (Budapest: Osiris, 1998), 332–398, esp. 332–341. 178. Gortvay (1953), 82. Gortvay quotes influential doctors, such as Ferenc Gebhardt, Ferenc Toldy, Pál Bugát, who all lamented about the undeveloped state of the sciences and medicine in the period. 179. Lesky (1976), 10–11, 16. 180. Gortvay (1953), 82–83. 181. See ibid., 70; for the same phenomenon in Vienna, see Lesky (1976), 96–106. 182. Gortvay (1953), 81. 183. See Károly Kapronczay, “Magyar orvosi társulások története” (History of Hungarian Medical Societies), Orvosi Hetilap (Medical Weekly) 132 (1991) 16: 871–872. 184. See Kapronczay (1991), 871–872. On the history of the safeguarding of doctors’ interest, see Katalin Kapronczay, “Az orvosok érdekvédelmi törekvései a 19. századi Magyarországon a korabeli szaksajtó alapján” (Doctors’ Endeavours at the Defense of Self-Interest Based on nineteenth Century Professional Journals), Az Országos Orvostörténeti Könyvtár Közleményei (Publications of the National Library for the History of Medicine) 41–42 (1995–6): 165–81. 185. See Kornél Chyzer, A Magyar Orvosok és Természetvizsgálók Vándorgy˝ uléseinek története (The History of Hungarian Physicians and Naturalists’s Itinerary Assemblies) (Sátoraljaújhely, 1890). 186. “Szerkeszt˝ oségi” (Editorial), Orvosi Tár (Medical Collections) 1 (1831): v–vi. 187. Ibid. 188. On the language of teaching at the Medical Faculty, see H˝ ogyes (1896), 23. 189. “Szerkeszt˝ oségi” (1831), v-vi. 190. See Gortvay (1953), 87–101; Gyula Magyary-Kossa, “Bugát és a magyar orvosi nyelv” (Bugát and Hungarian Medical Language), in Magyar orvosi emlékek. Értekezések a magyar orvostörténelem

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köréb˝ol (Hungarian Medical Sources. Studies in Hungarian Medical History), Vol. 1 (Budapest: Magyar Orvosi Könyvkiadó Társulat, 1940e), 317–325. 191. In 1840, for example, only 30% of medical doctors wore Magyar surnames as against 49% German and 23% Slavic and other surnames. See list of doctors cited above. 192. Lajos Markusovszky, “Szerkeszt˝ oségi” (Editorial), Orvosi Hetilap (Medical Weekly) 1 (1857): 2–3. 193. Ibid., 7. 194. Ibid., 5–6. 195. Ibid., 7. 196. For public health and forensic councils as well as the 1876 Public Health Care Act, see: Sándor Székely, “On the Preparation of the Hungarian Health Care Act of 1876,” Az Országos Orvostörténeti Könyvtár Közleményei (Publications of the National Library for the History of Medicine) 66–68 (1973): 59–84; Lajos Varga, “A közegészségügy rendezése és helyzete hazánkban a múlt század utolsó negyedében” (The Organisation and Conditions of Public Health Care in Hungary in the Last Quarter of the Last Century), Az Országos Orvostörténeti Könyvtár Közleményei (Publications of the National Library for the History of Medicine) Supplement 1 (1962): 3–144; József Honti, “Az 1876. évi XIV. tc. és el˝ ozményei: Az Országos Közegészségügyi Tanács (1868), az Országos Közegészségügyi Egyesület (1886) és az Igazságügyi Orvosi Tanács (1890)” (On the 1876 XIV. Act, the National Public Health Council (1868), the National Public Health Society (1886), and the Forensic Medical Council (1890)) Orvosi Hetilap (Medical Weekly) 16 (1997): 1009–1011; Lajos Varga, Részletek a magyar közegészségügy történetéb˝ol (különös tekintettel az Országos Közegészségügyi Tanács megszervezése és els˝o negyedszázados m˝ uködésére) (Chapters from the History of Hungarian Public Health Care, with Special Attention to the Formation and 25-Years Work of the National Public Health Council) (Doctoral dissertation) (Budapest, 1960); Lajos Varga, “Az Országos Közegészségi Tanács kiemelked˝ o orvos tagjai (1868– 1893)” (Eminent Doctors in the National Public Health Council, 1686–1893), Az Országos Orvostörténeti Könyvtár Közleményei (Publications of the National Library for the History of Medicine) Supplement 2 (1964): 5–279.

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197. See Honti (1997), 1009–1011. 198. Since numerous aspects of psychiatric professionalisation are dealt with in the following chapters, here I only refer to the most important forums for publication and associations. 199. See Salgó (1890); Ern˝ o Moravcsik, A gyakorlati elmekórtan vázlata (Outline of Practical Psychopathology) (Budapest: Franklin Társulat, 1888); Ern˝ o Moravcsik, Gyakorlati elmekórtan (Practical Psychopathology) (Budapest: Magyar Orvosi Könyvkiadó, 1897), etc. 200. The First National Congress of Alienists assembled 72 psychiatrists from all over the country and involved governmental authorities and non-governmental experts in the debates. The composition of the participants is revealing. Those of the capital undoubtedly dominated the congress: 48 participants were from Budapest. Out of the 24 professionals from the countryside, three came from Gyula and one from each of 21 towns including Nagyszeben, Pozsony, Nagykálló, Eger, or Gyöngyös, all with important state asylums or psychiatric hospital wards, and Kolozsvár, the city with the second Medical Faculty in the country. Based on the participants’ professional designations, their institutional affiliation also shows interesting patterns. 18 were alienists from state and private mental asylums (13 from Budapest: Lipótmez˝ o, Angyalföld, and the Schwartzer institute). The next largest group represented hospital psychiatry: 12 hospital directors, three hospital chief doctors, one county chief doctor, one district doctor. In addition, 12 psychiatrists had the label of “university lecturer” while there were seven forensic doctors, and two “nerve doctors.” This suggests the prevalence of those from the mental asylums of the capital city (equally confirmed by the choice of topics for discussion). 201. See “Basic Regulations of the Nagyszeben National Lunatic Asylum,” 1862 No. 24,044 decree issued by the Transylvanian government authorities, in Kornél Chyzer, ed., Az egészségügyre vontakozó törvények és rendeletek gy˝ ujteménye. 1854–1894 (Collection of Laws and Decrees Concerning Health Care. 1854–1894) (Budapest: Dobrowsky és Franke, 1894), 2–7. For the history of the Nagyszeben institution, see Kálmán Pándy, Emlékkönyv a nagyszebeni m.k. állami elmegyógyintézet ötven éves fennállásának évfordulójára (‘Memorial Book’ for the 50th Anniversary

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of the Nagyszeben Hungarian Royal State Mental Institution) (Nagyszeben: Haiser György Nyomda, 1914). 202. See the 1881 XII Act concerning the establishment of an asylum for the care of incurable mental patients dangerous to the public and the 1883 XIV Act concerning further financial support for its equipments, in Chyzer (1894), 235–236, 268–269. On Angyalföld, see István Zsakó, Az angyalföldi elme- és ideggyógyintézet emlékkönyve (‘Memorial Book’ of the Angyalföld Mental- and Nervous Institute) (Budapest: Attila-Nyomda Részvénytársaság, 1933). 203. See more on this in Chapter 4. 204. Ministry of Interior (1901), 4. 205. These numbers are from Kovács and Katus (1987), 1119, 1129. 206. These numbers are from Viktor Karády, “A kolozsvári egyetem medikusai a magyar orvosi piacon (1872–1918)” (Medical Students of the Kolozsvár University in the Hungarian Medical Market), Educatio 2 (2002): 237–252. In 1910, the population of Hungary reached 18,264,000, see Ignác Romsics, Magyarország története a XX. században (The History of Hungary in the 20th Century) (Budapest: Osiris, 1999), 47. 207. Kovács and Katus (1987), 1119, 1129. 208. Based on numbers and charts provided in Emil Jurkiny, “A székesf˝ ovárosi közkórházügy fejl˝ odése” (The Development of Public Hospital Care in the Capital), Egészség (Health) 9 (1901): 208–209. 209. For detailed history of social reform and poor policy, see Susan Zimmermann, Prächtige Armut: Fürsorge, Kinderschutz und Sozialreform in Budapest. Das “sozialpolitische Laboratorium” der Doppelmonarchie im Vergleich zu Wien 1873–1914 (Sigmaringen: Thorbecke, 1997), and Gábor Gyáni, A szociálpolitika múltja Magyarországon (The Past of Social Policy in Hungary) (Budapest: 1994). Also see Zsuzsa Ferge, Fejezetek a magyar szegénypolitika történetéb˝ol (Chapters in the History of Hungarian Poor Policy) (Budapest: Magvet˝ o Kiadó, 1986); Andor Csizmadia, A szociális gondoskodás változásai Magyarországon (The Development of Social Care in Hungary) (Budapest: MTA Állam és Jogtudományi Intézete, 1977); the chapter “Jótékonyság és szociálpolitika” by Gyáni, in Gyáni and Kövér (2001), 363–379.

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210. For this argument, see Ferge (1986), 69; Magdolna BezerédyHertelendy, Aurél Hencz and Sámuel Zalágyi, Évszázados küzdelem hazánk egészségügyéért (A Century of Struggle for the Public Health Care in Hungary) (Budapest: Közgazdasági és Jogi Könyvkiadó, 1967). Unfortunately, there is no reliable and comprehensive modern history of Hungarian public health care. For studies on general public health care and the 1876 Act, see: Székely (1973), 59–84; Varga (1962), 3–144; Honti (1997), 1009–1011. See also Varga (1960). 211. I use “(local) community” for the Hungarian term “község.” In contemporary definition, “község” was the administrative unit that had a degree of administrative autonomy to organise its municipal administration by itself. See also Csizmadia (1977), 127, 125–135. 212. See Gyáni and Kövér (2001), 97. 213. Ibid. 214. The 1875 III Act concerning the recovery of costs of public health care provision, Chyzer (1894), 49–51. 215. In case of every patient admitted to a hospital or curing institution, the institute had to write a report based on which the following conditions could be defined: the patient’s domicile, financial circumstance and the person who was required to pay for the patient’s treatment. This was sent to the patient’s municipal authorities which had to make the necessary investigations to confirm the above conditions. If the patient left the institute before three months, the costs were due at the time of discharge; if the treatment continued, the institute sent the bill to the respective municipal authorities in every three months. See ibid. 216. Ibid. 217. See the 8th and 19th paragraphs of The 1875 III Act concerning the cover of costs of public health care provision in Chyzer (1894), 49–51. I discuss the requirements of seeking such permission from the Interior Ministry in Chapter 84. 218. See more on the 1876 Act below. 219. See paragraph 71 in Article X of the 1876 XIV Public Health Care Act, in Chyzer (1894), 81–82. 220. See paragraph 72 in Article X of the 1876 XIV Public Health Care Act in Chyzer (1894), 81–82.

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221. See Pólya (1842); Ferencz Schwartzer, A Budai Magán Elmeés Ideggyógyintézet tudósítója és tizenkét évi m˝ uködésének eredménye (Report on the Buda Private Mental and Nerve Institute and Its 12-Year Operation) (Buda: Ny. Bagó M, 1864); “Basic Regulations of the Nagyszeben National Lunatic Asylum,” 1862 No. 24,044 decree issued by the Transylvanian government authorities, in Chyzer (1894), 2–7; Budai Országos Tébolyda, Alapszerkezet a budai országos tébolyda számára (Foundation Regulations of the Buda National Lunatic Asylum) (Budapest, 1868). Discrepancies between the legal regulations and the actual practice of admission are discussed in Chapter 4. 222. See paragraph 73 in Article X of the 1876 XIV Public Health Care Act in Chyzer (1894), 81–82. 223. The importance and consequences of different regulations in public and private asylums/ hospitals are analysed in Chapter 4. 224. See paragraph 74 in Article X of the 1876 XIV Public Health Care Act in Chyzer (1894), 81–82. 225. See paragraph 75 in Article X of the 1876 XIV Public Health Care Act in Chyzer (1894), 81–82. 226. See paragraph 76 in Article X of the 1876 XIV Public Health Care Act in Chyzer (1894), 81–82. 227. See discussed in detail in Chapter 4. 228. See Ottó Babarczi Schwartzer, “Az elmebetegügyi törvény alapelvei” (Main Principles of the Mental Health Care Act), in Az 1902. évi október 26-án és 27-én Budapesten tartott Második Országos Elmeorvosi Értekezlet munkálatai (Proceedings of the Second National Alienist Congress, Held in Budapest, on 26–27 October 1902), ed. László Epstein (Budapest: Schmidl Sándor Könyvnyomdája, 1903), 32–106; Babarczi Schwartzer, Az elmebetegügyi törvény tervezete (The Mental Health Care Bill) (Budapest, 1910). 229. See discussed in detail in Chapter 4. 230. See 1898 XXI Act on covering public patient care, in Chyzer, Az egészségügyre vontakozó törvények és rendeletek gy˝ ujteménye. 1895– 1900 (Collection of Laws and Decrees Concerning Health Care. 1895–1900) (Budapest: Dobrowsky és Franke, 1900), 368–372. See more discussion of it in Zimmermann (1997), 25, 40, 117. 231. See paragraph 8 of 1898 XXI Act on covering public patient care, in Chyzer (1900), 370–371. See also 1898 No. 133,000 decree

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on hospitals issued by the Interior Ministry, in Chyzer (1900), 518–561, and 1898 No. 19,651 decree on dangerous mental patients treated in hospital psychiatric wards and mental asylums issued by the Interior Ministry, in Chyzer (1900), 420–421. 232. See paragraph 9 of 1898 XXI Act on covering public patient care, in Chyzer (1900), 370–371. Paragraph 10 still demanded the Interior Ministry’s permission in the case of poor patients’ admission. 233. Ministry of Interior (1901), 4–7. 234. Ibid., 4–7. 235. See Pándy (1905), 388, 391–392. Tibor Forbáth claims that, according to the results of the 1900 survey, there were 15,586 mentally disordered and 26,659 “idiots” in the country, altogether 42,245 people. See Tivadar Forbáth, Adatok a magyar szegényügy rendezéséhez (Data Concerning the Organisation of Poor Relief) (Budapest: Márkus Samu Könyvnyomdája, 1908), 90. 236. István Hollós was physician of Lipótmez˝ o mental institute for almost three decades. He published an article with statistics concerning 40 years of the Lipótmez˝ o patient population in the Medical Weekly in 1909, see: István Hollós, “A lipótmezei állami elmegyógyintézet 40 évi betegforgalma 1868–1908” (Patient Admissions and Discharges at the Lipótmez˝ o State Mental Institution During the 40 Years Between 1868–1908), Orvosi Hetilap (Medical Weekly) 53 (1909a) 18: 75–83. 237. Ibid., 77. 238. If we add the 120 beds of the Schwartzer asylum, the 200 of Nagyszeben, the hospitals of the Hospitaller Order (20 in Eger and the 170 beds in the new mental ward built in Buda in 1861), we already arrive at 500, while there were also a few hospital wards already caring for insane. 239. See Pándy (1905), 388, 391–392. 240. Hollós’ numbers support this: by 1909, the number of beds for mental patients was high above 6,000. See Hollós (1909a), 77. 241. Forbáth claims that at the end of 1906, altogether 2,295 mental patients were cared for in public mental asylums and 3,743 in psychiatric wards of state and public hospitals. Therefore, there are about 6,038 beds for mental patients in public institutions, and another 180 patients treated in family care organised in

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Dics˝ oszentmárton (see below). Compared to the approximately 44,000 deranged persons in the country, it meant that every seventh could be treated in institutions. See Forbáth (1908), 89–90. 242. Porter (2002), 95; Shorter (1997), 5. 243. Forbáth (1908), 90. 244. Porter (2002), 112. 245. Forbáth (1908), 90. 246. Porter (2002), 112. 247. Shorter (1997), 47. 248. I calculated these numbers from Shorter’s who gives the relevant number of inpatients for every 1,000 population: in England in 1859, 1.6 patient was hospitalised for every 1,000 population, in 1909: 3.7 patients for 1,000 people. See ibid., 47. 249. I arrived at this number based on the fact that 6,000 mental patients were treated in psychiatric institutions in a population of 16,830,000 in 1900. 250. Ministry of Interior (1901), 5–8. 251. Pándy (1905), 384. 252. See László Epstein, ed. Az 1900. évi október 28–29-én Budapesten tartott Els˝o Országos Elmeorvosi Értekezlet munkálatai (Proceedings of the First National Alienist Congress, Held in Budapest, on 28–29 October 1900) (Budapest: Pallas, 1901a). 253. Since these constitute the material covered in Chapter 6 with rich documentation, I do not provide references here, see Chapter 6. 254. See discussed in detail in Chapter 6. 255. See discussed in detail in Chapter 6. 256. The numbers related to Germany are from Emil Kraepelin’s 1918 book Hundert Jahre Psychiatrie quoted in Ferenc Pisztora, “A schizophrenia és a paranoid kórformák gyógyítási kísérletei a monarchia korabeli Magyarország különféle psychiátriai intézményeiben” (Attempts at the Treatment of Schizophrenia and Paranoid Disorders in Different Types of Psychiatric Institutions in Hungary during the Monarchy), Orvostörténeti Közlemények (Communicationes de Historia Artis Medicinae) 92 (1980), 53–87; 54. 257. See the example of Scola Medicinalis discussed above. Soon after the establishment of the Nagyszombat Medical Faculty, the need for patients at demonstrations was voiced. As a result, Maria

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Theresa ordered the town “hospital” (xenodochium) to provide doctors of surgery and internal medicine with patients for practical teaching purposes. See Nádudvari (1936), 62–63. But the efficient use of hospitals for clinical practice in teaching was still a long way to come. 258. H˝ ogyes (1896), 38. 259. Károly Vörös, “A m˝ uvel˝ odés keretei és intézményei”, in Magyarország története (The History of Hungary), Vol. 6/2. ed. Endre Kovács and László Katus (Budapest: Akadémiai Kiadó, 1987): 1408–1409. 260. See Nádudvari (1936), 613; Kollarits Béla, Joó István and Bajza Géza, eds., Magyarország gyógyintézeteinek évkönyve, 1934 (Yearbook of Hungary’s Hospitals, 1934) (Budapest: Pápai Ern˝ o Nyomda, 1935). Of course, most of these “modern” clinics had precedent institutions as wards set up in hospitals. 261. See its detailed history in Chapter 5. 262. See discussed above. 263. Shorter (1997), 69. 264. For the university psychiatric clinic, see Chapter 5.

CHAPTER 3

The Bourgeois Family World of the Private Asylum: The Schwartzer Enterprise from 1850

This chapter explores the intellectual universe of early Hungarian psychiatry and the world of Schwartzer’s private lunatic asylum. I examine how the psychiatric credits of the first Hungarian asylum—and thus of the first Hungarian alienist—were established in texts and embodied in the building and operation of the lunatic asylum. Following a brief biography of the Schwartzer family, I examine the claimed purposes, admission requirements and other conditions of Pólya and Schwartzer’s private asylums. Then I elaborate on Schwartzer’s idiosyncratic and eclectic theory of mental illness presented in his comprehensive work A lelki betegségek általános kór- és gyógytana, törvényszéki lélektannal (General Pathology and Treatment of Disorders of the Soul, with Forensic Psychology). To place Schwartzer’s ideas into context and to trace his intellectual roots, I give a brief overview of relevant influential interpretations of insanity and its treatment, as well as a brief account of the cultural milieu of early- nineteenth century medicine in Vienna and Pest. In the last section, I examine the moral treatment and the idea and practice of the therapeutic asylum with special attention paid to the doctor-patient relationship.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 E. Lafferton, Hungarian Psychiatry, Society and Politics in the Long Nineteenth Century, Mental Health in Historical Perspective, https://doi.org/10.1007/978-3-030-85706-6_3

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The Schwartzer Dynasty The founder of the Schwartzer Private Asylum and author of the first comprehensive book on mental pathology written in Hungarian, Ferenc Schwartzer (1818–1889), was hailed already in the late-nineteenth century as the father of Hungarian psychiatry. He came from a family of German origins, whose assimilation and integration into Hungarian society had been speedy and successful, as they could boast of eminent descendants in the sciences and among tradesmen. The Catholic Schwartzer family left Silesia to settle in Hungary, in Szekszárd and subsequently in the nearby Babarc in the eighteenth century.1 The head of the family settling down in Hungary, Ferenc (I) Schwartzer was a master cooper, and had three sons: Ferenc, Alajos and Antal. Ferenc (II) (1784–1852) continued his father’s profession, while Alajos became a successful wine merchant and developed good relationships with high-standing Hungarian politicians and European as well as American wine merchants. He wrote professional and political pamphlets, and one of his wines was displayed at the 1872 Vienna World Exhibition.2 Of special importance from the point of view of the asylum-founder Ferenc Schwartzer was his uncle, Antal Schwartzer (1780–1834), who following his studies in Vienna was a teacher at the Vác Royal National Institute for the Deaf and Dumb for 26 years from its establishment in 1802 till his death. Antal even developed a special teaching method for the deaf and dumb that remained influential in Hungary for decades. His son, Károly was also working at the deaf and dumb institute for 47 years, directing it from 1873 to 1889, and publishing widely on the issue.3 Antal supported his nephew, Ferenc (III) Schwartzer both financially and spiritually, and Ferenc turned towards the sciences, studied at the Vienna Medical faculty and dedicated his 1844 dissertation on the education of deaf and dumb to his uncle. He began to work first at the dermatological department and then the mental ward of the Allgemeines Krankenhaus in Vienna.4 Thus, entrepreneurial spirit and an interest in mental deficiency ran deep in the family, and their Hungarian national sentiment was also undoubtedly getting stronger by the middle of the century. In 1848 Károly “magyarized” his family name to Fekete, and Ferenc (II) is also listed as Fekete among the doctors in the 1848–1849 War of Independence first as captain, then as the chief doctor of the IV. army corps, and finally as a surgeon-major.5

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In the meantime, Ferenc (III) Schwartzer became an enthusiastic supporter of the idea of establishing the first state lunatic asylum in the Hungarian Kingdom. Still a doctor at the Viennese mental ward, he turned to Palatine István and successfully requested support for a trip to foreign lunatic asylums. He travelled widely in Europe on state money, visited mental institutions in Czech and German lands, England, Belgium and France between April and July 1848.6 He hoped to use his acquired knowledge and experience in the building of a Hungarian institution and had already suggested the site where the Lipótmez˝ o State Lunatic Asylum as later built.7 In 1850, Ferenc Schwartzer settled in Vác (40 kms to the North of Buda), where, after his abortive lobbying in favour of a public national asylum, he finally received permission for establishing a private madhouse. At last, the first mentally disturbed patients (even if from only the wealthy upper classes) could step over the threshold of a “modern” institution to seek treatment in the Hungarian Kingdom. Opened in 1850, the asylum was two years later moved to Buda where it functioned as the family’s private enterprise through 1910,8 and under different ownership until 1945. The Schwartzer family became the most influential Hungarian alienist9 dynasty in the period: their work spread from 1840s to 1910.10 From 1855, Ferenc Schwartzer was a member of the Health Committee of the Council of Governor-General, in 1861, became the first privatdozent lecturing on mental health and pathology at the Pest Medical Faculty, and in 1868, became a member of the National Public Health Council.12 In 1872 he was named Royal Councillor,13 and in 1884 received the noble title and name “babarczi” for his achievements in the sphere of mental health care.14 Ferenc Schwartzer died in 1889.15 His son, Ottó Babarczi Schwartzer (1853–1913) ardently worked on settling the legal conditions and defence of mental patients and became one of the most eminent forensic psychiatrists. He was the founder of modern nursetraining in the country, reorganised the Hungarian Red Cross, and in 1901 became the vice-president of the National Public Health Council.16 He was a member of the Table of Magnates in the Parliament, and, in 1909, received a barony for his work in improving the Elisabeth Hospital of the Red Cross . Among lawyers, barons and counts, his name is 13th on the Budapest “virilista” list, the list of the greatest tax-payers in the years 1910–1912.17 He was also the first villa-owner in Balatonboglár.

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The Private Asylum Pólya’s Asylum Even though in Hungarian history of psychiatry, it is a general topos that the first “modern” asylum was the Schwartzer private madhouse, 18 the “cradle of mental pathological studies in Hungary” that educated the “first generation of our nation’s alienists,”19 Schwartzer’s private lunatic asylum was in fact preceded by a similar institution established by József Pólya (1802–1873) in 1841 in Pest, close to the site where later the Angyalföld Public Asylum was built.20 Pólya was chief doctor at Saint Roch Hospital where he had experience in treating mad patients and published case studies and a longer piece entitled “Szellemkórok” (Mental Pathologies) in Orvosi Tár (Medical Collections).Although Pólya’s small asylum catered only for 10–12 lunatics, great hopes were attached to the new institution. In his article praising the asylum in 1841, Bugát was hoping that the institute would be enlarged for 50 or even 100 patients in the future and rejoiced over the fact that medical students could finally gain expertise at the madhouse.22 The asylum, however, was closed after a couple of years because the annual cost of care and treatment was too high.23 The claimed purposes of the private asylum and its basic regulations reveal a keen stress on the institutes’ medical qualities. Pólya’s private asylum had two explicit goals laid down in the pamphlet he published upon the asylum’s opening.24 The first aim was to “provide medical help to mental patients (elmekórosok),” the second “to provide occasion for doctors to gain insight into mental pathologies.” In his explanation, Pólya stressed that it was in “the interest of science that the treatment of these unfortunate people not be undertaken—as it has so far been the case in our country—by people uncultivated in science, that the observations and their results not be lost to the detriment of science.” In addition, Pólya believed that relatives would be relieved to know that they had a choice other than the costlier solution of taking their insane kin abroad. As to the second aim, Pólya found it desirable for young medical students and practitioners to gain more expertise in the field in a “local” institution.25 In the lack of any established teaching in mental pathology, Pólya defined his expertise based on his private and hospital clinical experience: The successful results that have attended my efforts with mental patients in both hospital as well as private praxis, my attraction to the object (of

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mental pathology), and my firm grounding in science show promise that the place (of the asylum), dedicated only to those suffering from mental illnesses, will be more adequately used not only for my beloved science, but also for humanity. (2)

According to his description of admission procedures, Pólya required the “preliminary submission of an exhaustive, honest diagnosis and an account—which hides nothing—about the previous life, diseases, and present case of the patient, together with a proof of the patient’s pathological mental state written by a health officer or the municipal authorities” (2). A very important addition followed, “wishing, by all means, to be spared admitting patients based on the suspicion of mental illness, the institute announces that it will not debase itself to be the site for such misuse” (ital. mine) (2). In Pólya’s mind, all the required documents and the preliminary certificate were to ensure the institute’s good reputation: the patient’s “exhaustive and honest” life and disease history, written proof by authorities, and a stress on the scientific footing of the institute were all mobilised to guarantee professional and moral credibility. Schwartzer’s Asylum After years of experience and work at the mental ward of the Viennese public hospital and many visits to foreign institutions, Ferenc Schwartzer “opened a private lunatic asylum furnished neatly and with delicate expertise, on his own expense”26 —as an appraising journal article in 1861 stated. Original established in Vác in 1850, the asylum was moved to Buda27 in 1852, and for half a century, Schwartzer’s lunatic asylum remained the only private enterprise for the care of the insane in the country (Fig. 3.1). Admission of mental patients at Schwartzer’s asylum was based on the recommendation of the parents, guardian or district authorities. Schwartzer also required the attachment of a certificate by the relevant authorities or the doctor who previously treated the patient regarding the patient’s “real” mental illness, with a statement whether the patient was sent to the institution for treatment or for “being rendered harmless.” Since the claimed purpose of the asylum was cure, except for the truly hopeless cases of “idiots” and “imbeciles,” all kinds of mental and nervous patients were accepted.28

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Fig. 3.1 Bath-house at Schwartzer’s Private Mental and Nerve Institution (Photo) (Ottó Babarczi Schwartzer, Prospect der Privat-Heilanstalt für Gemüths und Nervenkranke zu Budapest [Budapest: Druck von Viktor Hornyánszky, 1897])

Patients were officially discharged from the Schwartzer asylum if they were found cured or were transferred to other institutions. The relatives could remove a patient they voluntarily brought within its walls whenever they wished, provided that they notified the director about this decision two weeks earlier. The reason for this interval seems to have been purely economic: the private institution was not supposed to lose income, and the admission of new patients required some time. Thus, it was specified that, if relatives failed to notify the director in time, they had to pay the cost of provision for the two weeks, even if the patient left the institute.29 It was the immediate interest of the private entrepreneur to impose a strict control over the financial conditions of admission. The costs of medical treatment and provision for the first 1- or 3-months had to be pre-paid, and if a patient died in the institute, the relatives had to meet the costs of the funeral. Provision costs varied according to the degree of luxury guaranteed. Patients sharing a room paid 50 forints, those

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living in separate rooms 70 forints, and the few staying in separate room and also requiring a separate nurse paid 100 forints per month. Apart from medical attendance and medication, these fees included accommodations in a nicely furnished room, meals, care, service and laundry. Schwartzer stressed that food and drink were supplied with the greatest care, and always matched the individual conditions and needs of each patient. Upper-middle class and wealthy patients were explicitly promised to receive a quality of life they were accustomed to.30 Sophisticated taste mingled with expert knowledge. Being a private asylum in a country without other specialised institutions, the asylum naturally catered to the wealthy and middle-classes. Based on Schwartzer’s statistics of the first 14 years, of the 357 patients treated in this period, 204 (57%) belonged to the “more educated class,” 131 (37%) to the lower-middle class, and only 22 (6%) to the lower classes.31 Originally planned for 60 patients, the asylum was gradually enlarged and, by 1863, could house 120. The organisation of the patients within the buildings suggests an economic and systematic management of inmates on the clear separating principles of type of illness, gender and degree of restlessness. For the first decade and a-half, all inmates were generally designated as “lunatics”. In 1863, however, Schwartzer built new houses to host about 20 “nerve-patients” which were divided from the houses of the roughly 100 “mental patients” by a road.32 In the main building and its two side-wings, there resided the mental patients: one wing for calm male, and the other for calm female patients, with a separate building for the restless. Schwartzer regarded it important to wisely plan the location and structure of the asylum, since the insane “try to avoid coldness and prefer warmth, are very sensitive to cold, and easily grow feeble.” He believed that coldness and obscurity could be beneficial for acute patients, while chronic patients were allowed to move freely in the fresh air. “Novelistic landscape” was especially beneficial for melancholic patients.33 According to Schwartzer’s description, the corridors were wide and light, and the windows were everywhere covered with “light, not deterring” white rails. Mental patients’ rooms were high, nicely painted and, due to their social stance, delicately furnished. They were of different size, some occupied by one inmate, some by two or more. At the same time, nervous patients lived in spacious apartments that resembled normal flats. Both men and women had separate parlours, and there was a skittle-room and a “playing” room for men, and a piano room for women.34 The two

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sexes had separate gardens and walking paths around the buildings,35 and the institution was also equipped with bathing and shower houses, and a separate laundry house (Fig. 3.2). In 1889, when Ferenc Schwartzer’s son, Ottó Babarczi Schwartzer (1853–1913) took over directing the institute, the asylum hosted 120 patients and constituted 15 pavilions, 8 gardens and 2 farm-yards.36 It still catered for mostly wealthy paying patients, but mentally disordered officers from the Hungarian as well as the common army were also sent to the institution by the Hungarian Minister of National Defence. The Interior Ministry also sent a limited number of patients, and there were a few places funded by different foundations.37 Following the spread of the use of morphine and cocaine in certain segments of society, new types of patients appeared: those suffering from “morphinism” or “cocainism.”

Fig. 3.2 Garden scene at Schwartzer’s Private Mental and Nerve Institution (Photo) (Babarczi Schwartzer, 1897)

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Laboratory of the Human Body and Soul: Schwartzer’s Comprehensive Theory of Mental Illness in Context In 1858, after 8 years of experience with mental patients at his own institution, Schwartzer published a book entitled A lelki betegségek általános kór- és gyógytana, törvényszéki lélektannal (General Pathology and Treatment of Disorders of the Soul, with Forensic Psychology). In the title, Schwartzer introduces the terms “psychic disorders” (or: “disorders of the soul”) and uses them as synonymous with mental pathology throughout the book. He defines mental pathology as the “long and feverless process of the pathological confusion of psychic powers, which robs man of his capability to think and act freely concerning his own well-being, care and responsibility.”38 The book was immediately hailed as “a new testament on the heavenly altar of our national language, … a generous guide in an untrodden oasis, … a fresh spring in a bleak desert.”39 It has since been regarded as the first comprehensive book on mental pathology written by a Hungarian in the mother tongue. Although not stated explicitly, the cohesive force behind Schwartzer’s view of mental disorders is the age-old medical theory of humoral pathology, which had characterised medical thinking from ancient times through the late-eighteenth century and beyond. In this holistic view, the human being is an inseparable unity of mind, body an environment, and his health is also influenced by natural forces of climate, season and geography. Schwartzer described the internal world of the individual as an elaborate economy of all the bodily processes, powers, fluids and heat, upon which the external world exerts its influence. In this sense, the human being arises in Schwartzer’s book as a kind of laboratory where internal processes are observed, the body and soul are translated into qualitative and quantitative factors and changes that determine the state of the observed subject, and where the overturned balance has to be restored with influencing inner processes qualitatively and quantitatively as well. The marked presence of humoral pathology in Schwartzer’s book is striking in the light of late-eighteenth century advances in neuroanatomy and physiology which provided powerful new theories of the workings of the “animal economy” (that is, physiological balance) and contributed to the waning of humoralism. His theory of mental illness and notions of therapy at the same time incorporated a unique mixture of other medical and psychological traditions and is remarkably idiosyncratic and eclectic in

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nature. In order to understand the complex world of Schwartzer’s ideas, I briefly review the psychological theories influential from the second part of the eighteenth century and describe the medical culture in which Schwartzer’s ideas were embedded. Enlightenment and Romantic Traditions in the Culture of Austro-Hungarian Medicine Western Theories of the Mind For many centuries, the general theory that underlay medical thinking and therapy in general, as well as insanity in particular was humoralism. In this system, health and illness depended on the balance or imbalance of inner fluids. Knowledge of the person’s state was obtained from visible body excretions (excrement, urine, blood, sweat, vomit, etc.), and therapy consisted of qualitative and quantitative interference in the body’s fluid and heat economy, for instance through dietetics, bloodletting, purgation and the use of sedatives.40 The four vitality-sustaining humours or fluids of the body: blood (source of vitality), choler (or yellow bile, gastric juice, for digestion), phlegm (all colourless secretions like sweat, tears, fluids flowing from the nose, etc., a lubricant and coolant) and melancholy (or black bile, darkening other fluids) carried different qualities (hotcold, dry-moist) and determined bodily characteristics of temperature, colour and texture as well as the “temperaments” (later synonymous with personality or psychological dispositions). The four basic temperaments were sanguine, choleric, phlegmatic and melancholic.41 In this theoretical system, therefore, physical and psychic characteristics were derived from observable material factors. Enlightenment science, more specifically eighteenth-century anatomical and physiological research, however, created new models of the animal economy “laying more stress upon the solids than the fluids, upon local organs and lesions rather than general metabolic equilibrium, and specifically upon the brain rather than the abdomen.”42 An important precursor, Thomas Willis’ (1621–1675) anatomical research in the nervous system in the second part of the seventeenth century made the brain the ultimate centre of the nervous system as well as the seat of consciousness. Neurological activity was explained with animal spirits as intermediaries between body and mind dispersed in all parts of the body via the nervous system. Focus on the nerves gave rise to the notion that mental illnesses had a distinct pathology related to brain

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lesions. Willis advanced ideas about the nervous origins of convulsive disorders like epilepsy, coined the term “neurologie,” and has been hailed as the founder of neuroanatomy and neuro-physiology. Willis’s theory, however, did not revolutionise therapeutics, especially the treatment of the insane.43 The Leiden professor Herman Boerhaave (1668–1738) developed a mechanistic disease conception explaining health in terms of hydrostatic equilibrium and distinguished between diseases of the solid parts and those of the blood and humours.44 His overly mechanistic explanations understanding the vascular system as well as the nerves as hollow pipes were however rejected by new physiological research which focussed on the nervous system made up of a network of fibres or wires. Albrecht von Haller (1708–1777) in Göttingen, William Cullen (1710–1790) in Edinburgh and others advanced a more dynamic life-force physiology in which stress was placed on vital qualities such as sensibility and irritability, and health consisted of the coordination of each organ’s separate life within the body. Cullen and Robert Whytt’s (1714–1766) research of the nerves related diseases to the disorders of the nervous system through nervous excitation. Cullen coined the term “neurosis” to cover a pool of specific diseases of the nervous system that caused sensory-motor alterations. In Cullen’s classification, insanity became an important group of neuroses and a distinct disease entity, rather than merely a group of abnormal symptoms.45 The most influential representative of this dynamic-vitalistic understanding of the body’s functioning was one of Cullen’s students, the Scottish physician John Brown (1735–1788). For Brown, life was induced and maintained by internal and external stimuli of heat, air, food, musclemovement and emotions; stimuli acted upon a force within the living organism called “excitability.”46 Brown reduced questions of health to variations of irritability or excitability, and sickness was the disturbance of the proper functioning of “excitement”: too little or too much stimuli caused disorders. For instance, mania was a state of over-excitement, melancholy of under-excitement (“sthenic” and “asthenic” conditions). For treatment, Brown recommended counterbalancing by opposites with different measures of sedatives and stimulants: mania had to be fought with sedatives (first of all, opium, but also purgatives, laxatives, expectorants), while melancholy required stimulants (opium could be used here, as well as camphor, cinchona bark and especially alcohol).47 In this

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dynamic-vitalistic conceptualisation of the body, the fluids of traditional humoralism had little significance. The dynamic-vitalistic trend represented a fairly organ-based trend, even though by combining the neurological activities of the organism with mental and sensational phenomena like the association of ideas, judgement, perception and emotions, Cullen did manage to integrate psychological aspects of his organically grounded theory. In other words, he gave a proper medical interpretation of the phenomena in the mental realm.48 Another influential trend, which emerged in the wake of Enlightenment medicine, is often termed “Romantic psychiatry”, which was more explicitly psychological in orientation and had a strong preoccupation with the irrational depths of the psyche and an obsession with morals and passions. Represented by the works of the Leipzig Lutheran Pietist Johann Christian Heinroth (1773–1843) and the Berlin doctor Karl Wilhelm Ideler (1795–1860), Romantic psychiatry was characterised by metaphysical explications of the inner consciousness. Heinroth gave a religious interpretation of mental disorders and understood madness in moral terms connected to sin and rejecting any physical relationship. In Romantic psychiatry, psychosocial factors (of family background, profession, age, sex, etc.) became dominant.49 The Medical Culture of Nineteenth-Century Vienna and Pest The specific political conditions of medical culture in Vienna and Pest greatly determined when and what kinds of theories could exert their influence at the medical faculties.50 In the second part of the eighteenth century, Gerard van Swieten’s reforms contributed to turning the Viennese Medical Faculty into one of the best medical schools in Europe. The Boerhaave-student van Swieten integrated his master’s work into the curriculum thus introducing Boerhaave’s novel theories as well as bedside clinical practice which were progressive trends at the time.51 As Erna Lesky discussed in her classic study on the Vienna medical school, at the height of the First Vienna School’s successful period in the years 1795–1803, two new theories electrified Viennese medical circles. One was Brown’s vitalism (generally called Brunonianism), the other Joseph Gall’s (1758–1828) phrenology. Brown’s ideas reached Vienna indirectly, via Johann Peter Frank (1745–1821) who was appointed director of the Viennese General Hospital and professor of the medical clinic in 1795. The German-born Gall was living in the Austrian capital at

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the time he outlined his theory of phrenology. Between 1795 and 1805, Frank and Gall worked in Vienna and represented new challenges to the old medical establishment. Both men, however, were detested and their doctrines rejected by Joseph Andreas Stifft (1760–1836) personal physician of Emperor Franz II. The increasingly powerful Stifft managed to oust both Frank and Gall by 1805.52 Viennese as well as Hungarian medicine had been firmly grounded in humoralism advocated by the influential internist Maximilian Stoll (1742– 1787), which was shaken by the arrival of Brunonianism’s new excitation theory. In Viennese medicine dynamic-vitalistic interpretations had never gained ground before, one-half a century earlier even Haller’s theory of irritability had been rejected. By advocating Brunonian vitalistic medicine, the new head of the clinic, Peter Frank declared war on the old traditions: instead of the “emptying or debilitating method” (of bloodletting, etc.), Frank advocated the invigorating method (the reliance on stimulants) (9– 10). Even though within a couple of years, the Brunonian movement became powerful and widespread in Vienna and Pest, by 1800, counterreactions also gained strength. Its chief leader was Stifft, who became the Protomedicus, Praeses and Director of the Faculty of Medicine in Vienna from 1803 to 1836. In line with the court’s post-1795 policy characterised by conservatism and restoration as a response to the Jacobinic movement, Stifft’s programme was a “medical restoration program” against the Brunonian “medical Jacobinism” (10–11, 16–20). Intellectually, Stifft’s programme meant the prohibition of the “materialist” Gall and Frank’s works and the restoration of humoral pathology a la Stoll. The new curriculum’s compulsory list of textbooks brought back Boerhaave’s and Stoll’s works, and the conservative sentiment prevailing at the Medical Faculty “was likely to reduce a generation of physicians to the level of mechanical medical artisans, and to encourage general regimentation instead of developing individuality, which is so very desirable in medicine” (18). Stifft also had the students’ “moral aptitudes” checked by the supreme study authority, as well as supervised professors’ behaviour and teaching methods. Ideologically unreliable professors were persecuted and removed (17). In terms of medical treatment and research, the Stifft era meant detailed bedside medicine (limited to a small number of patients) at the time when the Paris school of medicine was switching from bedside medicine to hospital medicine, which allowed a much larger set of

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observations. In short, the Viennese research programme based on Stoll could not be rationalised in contemporary terms.53 While French medical reformers made the development of physical diagnostics the centre of their research programme and advocated a new examinationoriented medicine in the early decades of the nineteenth century, the Vienna school reinstituted the tradition of old Hippocratic-Boerhaaven observation-oriented medicine. In this tradition, the hidden interrelations between weather and disease as well as medical topography dominated Austrian literature. There was a strong reliance on the ancient Hippocratic notion of the healing power of nature, which also meant a preference of decreased medical intervention, and the use of dietetics was popular.54 In spite of his conservative endeavours, Stifft could not defend the monopoly of humoral pathology in the long run: new ideas intruded and partly modified the medical orientations of the medical faculties as well as therapeutic practices in the Empire. Among these influences, most significant were the dynamic-vitalistic neuroscientific branch of Enlightenment medicine and the natural philosophical speculative line of Romantic medicine. These trends exerted their influence in quick succession and parallelly remained dominant in different quarters of research and therapeutics. As a consequence, during the first decades of the nineteenth century, various alternative therapeutic methods were used in Austria as well as Hungary, such as animal magnetism and homeopathy. Although these were met with different degrees of disapproval by the official medical establishment, their practice flourished in both countries. The Viennese father of magnetism or mesmerism, Anton Mesmer (1734–1825) was forced to move from Vienna, but his followers, Johann von Malfatti (1775–1859) and others continued the practice of magnetic healing.55 The movement had Hungarian followers from the second decade of the nineteenth century, but the hightime of magnetic healing fell in the 1840s when the “Hungarian pope” of magnetism, Count Ferencz Szapáry’s (1804–1875) books and practice received wide publicity.56 In spite of official rejection, homeopathy was also popular in Austria as well as Hungary from the second decade of the nineteenth century. A third therapeutic movement, hydrotherapy, also gained popularity in these decades.57 As in other German countries, Friedrich Wilhelm Joseph Schelling’s (1775–1854) natural philosophical system influenced medicine in Austria from the second decade of the nineteenth century.58 A notable example is the Moravian-born Georg Prochaska (Chair of Physiology in Vienna

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in 1791), who in his influential works on physiology assumed the existence of a nervous power which he considered to be a part of the vital power. By 1820, he replaced the notion of nervous power with the wider concept “life” or “the process of life.” Following the debates on the interpretation of the new discovery of the electrical phenomena in the muscles made by Luigi Galvani (1737–1798) in 1791, Prochaska, in the habit of natural philosophical speculation, ascribed separate galvanic process to every organ in the body.59 Prochaska’s theory was attacked by the subsequent Chair of Physiology, the Hungarian Mihály Lenhossék (1773–1840). Lenhossék was the chief physician of Esztergom county, a professor of physiology at the Pest Medical Faculty and, between 1820–1825, at the Viennese Faculty. Upon his return to Hungary, he became the country’s protomedicus .60 His 5-volume Physiologia medicinalis published in Pest in 1816–1818 was the first textbook in the Empire that discussed the results of comparative anatomy, a subject which was developing at the time. Although Lenhossék claimed to be a rational empiricist in physiology, his work also contained Romantic dynamic-vitalistic ideas. He assumed a separate “imponderable bioticum,” a second organising and also a third power of life.61 In the Romantic spirit, Lenhossék wrote extensively on human passions.62 He also wrote one of the first scholarly papers on animal magnetism in Hungarian.63 In the field of general pathology and therapy, natural philosophical speculations came to characterise Viennese medicine especially under Philipp Carl Hartmann (1773–1830). In his endeavours to provide a general synthesis and theory of medicine, Hartmann adopted a holistic view and paid attention to the inner dynamic processes as well. As opposed to Brunonian ideas which gave more weight to quantitative aspects of external stimuli, Hartmann believed that the nature of disease was more determined by qualitative forces of life within the organism. In Lesky’s assessment, Hartmann’s classification of diseases into dynamic ones (which depended on changes in the forces of life) and organisational diseases (dependant on mechanical disturbances) does not completely agree with today’s division of disorders into functional and organic, but it can be “considered a corrective of the preceding one-sidedly exogenous solidistic pathological view,”64 which embraced a psychosomatic perspective. Although he rejected Gall’s work, he accepted the need for the organic basis as an instrument of the spirit. Hartmann was also instrumental in establishing medical psychology in Vienna and his student,

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Ernst von Feuchtersleben became the first influential psychologist of the next generation (82). Stifft’s death in 1836 opened the way for reforms. Ludwig Baron von Türkheim (1777–1846) and young members of the Viennese Medical Faculty prepared a comprehensive reform plan, the implementation of which generated the Second Vienna Medical School (96–105). One of the most significant member of this group was Carl von Rokitansky (1804–1878), who, inspired by advances in Paris, believed that medical knowledge had to rely on patho-anatomical findings rather than natural philosophical speculations.65 Importantly, in his Handbuch der patologische Anatomie (1842–46) Rokitansky developed a neo-humoralism according to which diseases proceeded from an imbalance of protein substances in the blood,66 which is relevant to the understanding of Schwartzer’s theory. Aetiology of Mental Illnesses in Schwartzer’ Theory In his eclectic book, the A lelki betegségek általános kór- és gyógytana, törvényszéki lélektana (General Pathology and Treatment of Disorders of the Soul, with Forensic Psychology), the Vienna-trained Schwartzer offered an idiosyncratic integration of humoralism, Enlightenment dynamic-vitalism and Romantic psychology with his own empirical observations. Tracing his intellectual influences is somewhat difficult since he often did not carefully name his sources. Thinkers, such as Philippe Pinel (1745–1826), Jean-Pierre Falret (1794–1870), and Johann Christian August Heinroth (1773–1843) from the first decades of the nineteenth century are named here and there, Jean-Étienne Dominique Esquirol (1772–1840) being one of the main authorities.67 Predisposing Causes In Schwartzer’s understanding, the human psyche was exposed to a complexity of biological, environmental and social factors which could affect sanity. Discussing the aetiology of mental illness, he differentiated between predisposing and precipitating (or triggering) causes. Among the physical and psychic predisposing factors, he enumerated the following: illnesses,68 constitutional dispositions, “blood-constitution” or temperament, the sex and age of the patient, the influence of seasons and climate, education, profession, illnesses, religion and even the form of government. Many elements in Schwartzer’s understanding of the nature of

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mental disorders had been considered as significant in previous decades and remained so—sometimes transformed—in the upcoming decades as well. Climate, seasons, age, sex, temperament, profession and lifestyle for instance were also described as crucial factors in Esquirol’s seminal work Des maladies mentales.69 Schwartzer employed theories of inheritability and the already discussed dynamic-vitalism to account for constitutional dispositions . He differentiated the following types: physical or psychic disposition inherited from parents through three generations; disposition not inherited but born with (if the parents procreated at an old age; or, if the mother experienced great fright or fear during pregnancy, the child was supposed to be predisposed to mental illness). Dispositions could also be acquired gradually throughout childhood if the nerves and the vital powers were affected by masturbation, premature licentious sexual conversation, improper education, the spoiling of the child, too rich food and even physical or mental overexertion, all of which increased sensitivity which predisposed the brain to mental illness.70 The idea of inheritability was further developed throughout Europe in the second part of the nineteenth century to become one of the most influential theories that pervaded not only scientific thinking, but also became a rich social and cultural metaphor: the theory of degeneration. Schwartzer’s emphasis on the nerves and their over-exertion builds on the underlying logic of “nervousness,” another swaying and powerful theory that would conquer fin-de-siècle psychiatry and society.71 That Schwartzer named “blood-constitution” or temperament as another predisposing factor clearly belongs to the old humoral tradition. His views showed a refined relationship between quality and quantity: each blood-constitution favoured the development of certain instincts which could grow into passions. If these became excessive or dominant, they developed into mental illness. Cold blood-constitution (temperament phlegmaticum) made one disposed towards “calmness.” Two “terrible mental pathological predispositions may arise from this: avarice and cowardice,” which, if they pervaded the entire temperament and became dominant, may have brought about madness.72 By contrast, full-blooded blood-constitution (temperament sangvinicum) made one sensitive to fickle stimuli and changes, too reliant on external values, and susceptible to a desire for pleasures and vanity. If these became excessive,

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a strong stimulus could give rise to mental pathology. Bilious bloodconstitution (temperament cholericum) was characterised by great irritability, which advanced raging madness and partial mania. Finally, dark blood-constitution (temperament melancholicum), where the “abdominal entrails become dominant,” could lead to melancholy (47). While these basic temperaments had formed part of a general medical knowledge for centuries, Schwartzer further elaborated their different physical and mental qualities based on his observations and thus created subtypes: In general, black-haired, strong-muscled, hot-blooded individuals have a tendency for raging, the course of their disease is quicker, their symptoms are more striking. Blue-eyed, blond, cold-blooded people … usually come to suffer from mania, and their disorder more easily transform into chronic disease: vesania. Black-eyed and haired, nervous individuals mostly fall prey to melancholy. Red-haired people become maniacs; they are squealing and dangerous. (47–48)

In order to prove that the blood-constitution carried “significant psychic meanings,” Schwartzer referred to Heinroth’s belief that “bloodtransfusion would bring about vivification in case of “idiots” and melancholic patients. Young, healthy and strong animal’s blood was to be used, which—as Schwartzer explained—carried extreme vitality. In support, he listed examples of successful cures achieved by a doctor called Denis, who transfused lamb blood into a melancholic and calf blood into a man suffering from love madness (81). Even though Schwartzer mentioned that the shape, constitution and size of the skull “allegedly reveal mental pathology,” he nevertheless concluded that research into the matter had not so far produced any convincing proof (48). Schwartzer’s disregard of Gall’s phrenology73 is probably explicable with the strong rejection of the theory in Vienna at the beginning of the century which prevented it from exerting its influence in the following decades in both Vienna and Pest. Further research needs to substantiate how influential phrenology was in academic circles and how widespread as a cultural practice in Hungary.74 By 1858, new theories had come to the fore and phrenology was mostly discredited, but apart from the influence of modern research into brain localisation (by Broca and others) after 1860,75 the study of the shape of the skull and its correspondence with brain functions had a renaissance in Hungary in the

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last decades of the nineteenth century. Observations were made on the visible stigmas of mental disorders (like in case of hysteria), on the brain of criminals and geniuses, as well as in research on brain localisation.76 By contrast, Schwartzer considered the sex of the patient an important predisposing factor, this way echoing traditional asymmetric attitudes. Despite claims of objectivity, nineteenth-century medical/scientific theories were no less saturated with gender categories than in earlier phases of medical history.77 Schwartzer shared the general notion that women were more predisposed to mental illness than men due to their more excitable senses and nervous system, their more violent passions, and due to the female reproductive cycle: the influence of pregnancy, giving birth and menstruation. Without using the word “hysteria”, Schwartzer nevertheless brought into the discussion notions of the traditional uteraltheory when he stated that due to the “relationship between the brain and the Mother (méhanya),” the illness of female body parts could affect brain function and produce psychic and temperamental changes. He also conceded that there could also be “moral causes” that first disturbed the function of the uterus which then affected the brain.78 In detailing the differences between sexes, apart from the biological argument, Schwartzer also brought in the “social” when he concluded that “numerous significant conditions related to bourgeois education, professions and lifestyle change the inner nature and life of the sex to such an extent that the original psychic imprint is no longer recognisable.” Social influence could manifest in different ways: “women’s desires and emotions are confined between more narrow constraints than men’s,” whereas women often “read works which excite their fantasy without developing their minds to the same degree” (48–50). In Schwartzer’s view, the age of the patient also had a potential impact on mental life. A specific mental illness could be rendered to each lifephase: idiocy to childhood, mania to years of youth, melancholy to a more mature age and vesania to old age. But it is adolescence which coincided with most mental disorders, due to grave bodily changes (50– 51). Such a direct and simplified matching of age with a specific mental disorder would disappear in subsequent works, although some disease forms did remain or become associated with certain age groups. For instance, while Schwartzer had left it out of his taxonomy, senile dementia became an independent disease form in subsequent works. The conviction

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that women’s reproductive cycle (especially adolescent changes, menstruation, lactation, childbirth, etc.) utterly influenced women’s mental state also remained powerful throughout the period.79 Following Rokitansky’s neo-humoralism of the 1840s, as well as popular thinking, Schwartzer believed in the great influence of seasons and climate. He assumed that Spring and Summer were the seasons of the “eruption” of mania, Autumn and Winter of melancholy. If healing happened during warm Summer days, it proved to be more lasting, whereas falling back to mental illness most frequently happened around the anniversary days of the original outbreak, he believed. Season also affected the course of mental illness: those who were excitable and maniacal in the Summer were likely to be in an opposite state during the Winter. “Madness changes its character due to the season.”80 Schwartzer’s belief that a long period of heat increased excitability, whereas continuous cold weather decreased was to be widely recounted in later literature as well.81 Schwartzer saw education as a crucial predisposing factor, mostly criticising the lack of restraint on the passions and will of youngsters; the neglect of the cultivation of self-restraint; overemphasis on the intellectual training and overexertion of the mind at the expense of the cultivation of the heart; over-stress put on financial success; and the over-excitation of the fantasy of girls with novels. He also stated that bourgeois expectations surrounding the (male) child’s education and subsequent career disregarded individual differences in mental capabilities, inner psychic nature and physical constitution. He found similar flaws in the education of girls, whose “unbridled love of the novelistic and vain life is cultivated rather than suppressed.”82 Although the dependence of mental health and disorders on a complex balance of internal forces and the overall harmony within the human economy would not be integrated into such a comprehensive theoretical formulation as Schwartzer’s, most of the factors do occur in subsequent psychiatric texts. Psychiatrists’ obsession with “nervousness” by the turn of the century is also founded on very similar explanations of the economy of internal powers, boosted by the latest neurological knowledge of the anatomy and function of the nervous system (vehemently studied in Hungary from the 1870s).83 In addition, the germs of degeneration theory are already there in Schwartzer’s work: he stated that the overexertion of the minds of youngsters with too much studying, if complemented with a weak constitution, results in the weakening of the generation.84

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Schwartzer also held that the form of government influenced not only the morals and passions of the nation, but also mental illnesses. He contrasted the low occurrence of mental illness in countries where despotic regimes “repress all discontent and passions,” such as Turkey, China and Mexico, with republican and representational governments that freed the passions, and thus greatly favoured mental illnesses. Similarly, mass movements and revolutions excited passions and stimulated the mind, increased ambitions, and quickly turned the wheel of fortune, changing people’s social stance, all of which negatively affected the human psyche.85 Such reasoning is logical since in Schwartzer’s overall theory of mental illness it was necessary to put constraints on excesses and passions in order to achieve a balance of inner and outer forces. While excesses have generally been seen as dangerous to mental balance throughout the history of psychiatry up to the present day, the notion of repression would become more refined by the turn of the century and acquire new meanings especially in psychoanalysis. Schwartzer also saw a predisposing factor in religion. He argued that religious thinking could not be “bridled” by empirical data, thus it placed man in the realm of fantasies. Only a rationally balanced mind could comprehend religion in its original clarity; for those who related religion to signs available to the senses, religious rituals lost their original function to cultivate the morals and degenerated into “idolisation through the senses.” The more the senses got involved in the practice of religion, the less moral influence it had, and the more space was created for fantasies and passions that led to religious madness (57). People’s professional activities have always been considered in psychiatric thinking as a crucial factor in the development of mental disorders, and in this respect, Schwartzer’s emphasis was again laid on balance and harmony: he advised a proportionate combination of intellectual and physical activities. Schwartzer believed that intellectual and scientific work in general strengthened the mind, and normally did not cause mental illness, since, if mental capabilities were gradually exercised and strengthened from childhood, it “defended the mind against illnesses.” Such a training, however, was supposed to exclude the over-excitation of fantasy, passions and the emotions. In case a scientist stayed up too late, slept little, neglected physical exercise, and had an unbalanced diet which disturbed digestion and excretion—all of which factors were in themselves sources of mental illness—such an irresponsible lifestyle led to cramps in

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the lower belly, disorderly secretion, repressed skin perspiration and finally contributed to spleen or melancholy (55). Schwartzer found mental illness especially frequent among artisans. Their rationality and mind were uncultivated, thus their fantasy was continuously lively and excited. Artists, actors, musicians, poets and singers paid the price of becoming vain with madness: they became exposed to the attacks of critiques and to professional strifes. Highly gifted scientists, poets and artists could keep their mind sane until old age, but they still might fell prey to madness because of a debauched lifestyle or dietary problems (54–55). Offering a social criticism disguised in psychiatric concepts of degrees and qualities, Schwartzer discussed the effects of early industrialisation in the country. He claimed that early business owners and managers who made up a wealthy class in bourgeois society were not dangerously exposed to the causes of mental illness. But now, as merchants dive into the most dangerous enterprises, and a few days may either make him rich or bankrupt, and as every political change fills him with fear or hope: this class has lost its former peace and can show up as many mentally disordered among its ranks as the class of artists and scientists. (56)

The monotonous occupation of workers and artisans, especially in a sitting job, pathologically affected the chest and lower belly, which may have led to spleen, melancholy and suicide. Workers were also exposed to lead-steam in factories that may have produced a special form of madness. Miners, who were “deprived of everything that is pleasant in life,” and who were constantly aware of the dangers threatening them, turned melancholic due to the constant rigidity of life. Painters working with indigo were supposed to be sad and morose (56). Schwartzer’s mid-century theorising thus already contained a form of social criticism that grew ever more emphatic as the century approached its end. Energetic urbanisation and capitalisation brought about huge social changes in Hungary in the last decades of the century that were more drastic in the period than anywhere else in the West and psychiatry’s critical function became manifest in degeneration theory as well as in the huge psychiatric literature on nervousness, alcoholism, prostitution and pauperism.86

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Precipitating Causes When enumerating the precipitating or triggering causes, Schwartzer differentiated psychic and physical ones, and believed that the former dominated the latter, since “these always involve the passions,” just like “general bourgeois and political movements dominate all classes of society” (58). The description of precipitating physical causes again shows a strong reliance on dynamic-vitalistic theory and emphasises the role of the brain and the nerves while the interpretation of psychic causes relies on psychological explanations. The precipitating physical causes include three subcategories. First, those directly affecting the brain, such as the heat of the sun, the “thickness” of the blood in the brain, epileptic or convulsive fits, paralytic strokes or external traumas to the head (72–73). Second, Schwartzer described causes that exhaust the organic nervous power87 and he proposed a complex “economics of mental life” (szellemi élet gazdászata) in which “whenever mental disease is connected to nervous illness, some organic problem can be suspected with great certainty, the seat of which is either in the brain or the spinal cord” (87). For treatment, Schwartzer suggested traditional vitalistic remedies, like narcotic drugs and stimulants (wine, brandy) (74–75). The third kind of causes included diseases of organs which the brain had congenial relationship with. Schwartzer in fact conceived all organs to be in a mutual relationship with the “soul” via the nerves and the brain and this way diseases of the intestines, liver, urinary organs or the heart for example, as well as disorders of the blood-circulatory system, congestion, hyperaemia and even respiratory disturbances88 could become “terrible sources of mental illnesses.” A prolonged inflammation of the small intestines, for instance, caused suicidal urges and melancholy (75–78). Many of his examples clearly resonate with humoral pathology. For instance, “suppressed” menses meant that “the blood-circulation follows another direction and causes congestion towards the head, which attacks the brain” and may cause stupidity, mania, melancholy, deep sadness, anxious musings, suicidal urges and often religious madness (79). But the normal appearance of menstruation may also be accompanied with headache or nervous fits and Schwartzer mentioned one of his patients, a young girl who turned into a poet whenever her period came. During those days of the month she always “went mad” and “used eloquent rhymes in her expressions, although in a healthy state she demonstrated

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not the least poetic inclination” (79). His explanation for the pathological influences of childbed similarly resorted to humoral pathology (80). Schwartzer’s other main category was precipitating psychic causes: pathological qualitative or quantitative changes in sensations, feelings, and perceptions that brought about a breakdown in the refined functioning of the soul. People were conscious of the existence of their body through sensations, i.e. ‘the sensation of a general condition’(közérzet ), the weakening of which brought about a “decreased sense of the body” or its entire forgetting. This effect could result from the over-cultivation of higher mental faculties for instance, but bodily sensations could also be blunted by an excess of pleasure, a diminishing of the spiritual values resulting in weariness of life, which had no moral basis. If the soul exchanged its “real cause” for “moral” ones, it led to melancholy and even suicide. The bluntness of bodily sensations this way could result in a similarly blunt, “paralysed” soul and the person “degraded to a mere machine” (58–59). On the other hand, too much sensation could also become dangerous manifesting in the general condition (közérzet) as over-sensitivity or pain and in the soul (lelki érzet) as mood swings and fits of anger. This is because excessive bodily sensations over-intensified the sense of the body at the expense of the psychic and imaginative faculties, and the person became governed by his/her bodily life while the higher functions of the soul were suppressed. In the short run, this led to moral mistakes and disorders, but in the case of prolonged suppression, it resulted in mental dullness (58–60). Overly intense, long-lasting emotions gained dangerous dominance over other powers of the soul as well as over the will and judgement. Any such disproportion caused the person to live within his feelings, consciousness waned, free will faded, the use of reason disappeared and an over-powerful single emotion led to melancholy or raging madness (59–60). The moderate functioning of sensation was essential for the health of the body and soul, though what degree of sensation counted as healthy differed in each individual (58). Schwartzer also gave a refined explanation for feelings, obsessions and their mechanisms. Concerning delusions, for instance, the overintensification of the general inner condition (közérzet) could result in the imaginative faculty focussing too much on the inner processes.Under such circumstances, new sensations appear as uncertain or obscure, and easily produce delusions(62–72). A person suffering from such delusions is unable to find his or her real reason, and either looks for them outside

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of himself, or in himself, but misidentifies their location. This is how hallucinations and fixed ideas are given rise to. People can believe that “there are frogs … in their bodies, or birds in their heads, and that their body consists of glass, wax, or undried fresh butter.” Such faulty sensations result in faulty judgements and become the source of mental illness. Clearly in the Lockean psychological tradition, Schwartzer thus derived delusions from faulty sensations and wrong associations, not from the loss of the capability of reasoning. It is the faulty mental world constructed on faulty sensations that are taken as reality by the patient, not necessarily his impaired reasoning. Patient Observation Since the aetiology of mental illnesses encompassed the organs of the body, the age, sex and social conditions of the person, as well as his or her psychic operation, Schwartzer compiled an amazing list of all the conditions and factors that must be considered in the process of determining mental illness. The list included the examination of bodily features, facial expression, the eyes, the shape and parameters of the head, the mouth, the movement of the tongue, even the hair,89 the movement of the limbs, speech and the functioning of organs, the rhythm and might of pulsation, the stomach, intestinal canals, liver, kidneys, lungs and heart. Schwartzer further emphasised that the doctor had to “inquire about the senses, as well as about the dreams” of the patient, and collect all possible information on the prehistory of the patient from friends, relatives and guardian. He emphasised the importance of letters written by the patient, where even the way of folding the paper, the style of writing, and the way of addressing others were seen as “precious records concerning the mental state” (11). All this suggest a strikingly holistic interest in the individual case. Schwartzer and his assistant doctors, János Lyachovics and Károly Bolyó (1833–1906), emphasised their concern for “the patient’s entire mental personality”90 and strove to devise individualised treatments. Bolyó was the first to outline the principles of case history writing in Hungary in an article in Gyógyászat in 1862,91 which became exemplary for subsequently built state asylums, especially at Lipótmez˝ o National Lunatic Asylum where Bolyó worked as a ward doctor from 1868. Decades later, Schwartzer’s son, Babarczi Schwartzer included a case history sample in the reports he published on the institute, in which as many as 95 observable factors were enumerated.92

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The Therapeutic Asylum In Schwartzer’s view of madness, the asylum itself was the most efficient tool in the hands of the alienist. Isolation in the asylum that housed people with similar afflictions, guarded by walls that shut off all the troubling forces and noises of the outer world, was seen as therapeutic in itself. The assumed advantages of the asylum to the private home were numerous. It provided more careful tending, greater peace and less disturbance, it was more easily guarded, and the size of the asylum made the therapeutic moving of the patients from one room or flat to another possible.93 Schwartzer juxtaposed it with the prospect of the patient being tied to his bed in private homes, which—he claimed—only increased the person’s madness.94 Familial attitude towards the insane was often marked by shame and the wish to conceal it. The presence of a mentally disordered relative in the family was seen as not only unpleasant for the latter, but also therapeutically disadvantageous for the patient.95 Schwartzer’s assistant doctor also emphasised in 1861 what “a great shame a mentally disordered person is for the family.” “In the unfortunate lack of sufficient institutions, they are hidden at home, concealed from the world,” and left without treatment.96 Being among fellow mental patients was supposed to urge the patient to “muse about himself, [and] also provides him with entertainment and opportunity to deal with others, and thus forgets about himself,” which Schwartzer regarded as the first steps toward a cure. In the asylum, “new sensations arise, former delusions are broken, new influences stimulate attention.” Communication with fellow patients was seen as good exercise for the brain, it encouraged them to concentrate and collect their thoughts. Also, “since they are under serious discipline and are forced to follow an ordered life and diet, they are compelled to consider their situation,” and “from deprivation arise his desire for freedom and the wish to see his family.”97 With these claims and his stress on the “psychic” methods of treatment which he explicitly designated “moral therapy,” Schwartzer legitimised the existence of the asylum. Physical Treatment Before discussing moral therapy as the novel form of treatment in the therapeutic asylum, we need to briefly consider more traditional physical

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methods also used to achieve healing. In accordance with his theory of mental illness, Schwartzer’s general aim with physical therapy was to bring about both qualitative and quantitative changes in the person to restore the lost balance (91), and to cure organic diseases that disturbed mental functions. Thus, it was crucial to look for the source, and determine if there was need for urgent intervention. For instance, if menstruation was impeded, it had to be induced and a “suppressed ulcer or skin disease” had to be brought to light (99). If great blood-congestion appeared with excitement, bloodletting, lukewarm baths and sedative substances were used. Almost as a general rule, the insane were given refreshing drinks, purgatives, and were subjected to a light diet. Mustard applied to the skin also proved effective, Schwartzer claimed. A longer treatment was to remove all the potential “material causes,” but this must be complemented with a treatment “appropriate to the personality.” Physical exercise, riding, fencing and gardening were “to be included among the therapeutic tools” (98–99). If treatment did not bring about a cure and eliminate the organic problems, the doctor had to resort to “empirical therapeutic tools.” Schwartzer’s description of different forms of baths and showers combined with different temperature suggests a refined use of watertherapy in all forms of mental disorder. Some forms of its application seem to have been rather cruel and with the intent of disciplining (100–102). Physical therapies also involved manipulation with hunger and thirst, as well as the infliction of pain, since, “apart from the general influence of bodily pain on the soul, it also greatly affects the imaginative faculty, and is the best therapeutic tool in case of delusions” (102). While mental illnesses often derived from physical causes (these were usually regarded as more easily curable than those originating from the psyche) (87), Schwartzer believed that psychic and physical triggering causes and predisposing factors rarely exerted their influence individually but were usually combined (113). The control and treatment of physical problems traditionally formed part of any general doctor’s duty and could be carried out at home as well. Therefore, these tasks alone did not necessitate the separation of the patient from their environment and did not form a strong argument for the asylum. The legitimacy of the asylum derived instead from the “psychic” part of the treatment: the notion of the therapeutic asylum rested on psychic cure.

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Moral Treatment Psychic, or in Schwartzer’s term “moral” treatment did not consist of “master strokes,” the coercive shock of the spirit or the imagination, or in the “dangerous” method of “chasing away of a mad thought with another mad thought.” Rather, it was based on “the miraculous power of truth,” on “rational order” which pertained to everyone, and aimed at the pacification of the spirits, which so affected the clarity of cognition. Rational activity—“devoid of passions, the disturbance and gloom of psychic life— is the most effective and general remedy,” Schwartzer believed (8). The patients placed “under serious discipline, were compelled to follow an ordered life and diet, which compelled them to consider their situation.” This was supposed to bring patients back to reason and to kindle a longing for their previous life. Thus, psychic treatment built on the constant “serious and loving” reminder of the patient of his own rationality to increase “real moral freedom and self-restraint” (85, 8). Treatment was aimed at the “complete systematic re-education of the individual”98 and at leading patients back to their families and to society in large. The doctor “strove to give them back to the circle(s) that nature assigned for them, but from which upbringing, fate, their own leanings or aversions removed them.”99 Within the asylum, the first step is to accustom them to order, and not to allow them to neglect their duties, otherwise many would die of hunger and filth. Therefore, the patient is encouraged to wash himself every day, dress properly, rise and go to bed in time, and urged to do physical exercise.100

The gendered occupational and social activities offered at Schwartzer’s private institution, the emphasis on industriousness, work, and the daily routine suggest that life within the walls reflected everyday social life and dictated social norms prevailing in the outside world. It was here, within the walls that the patients had to be re-accustomed to bourgeois order. According to the house-rules, every day was spent rather similarly, as all patients—except for the ailing—got up at 6:00 am and went to sleep at 8:30 pm in the evening. The patients’ daily order from 1894 contains somewhat different times for waking and going to bed, but is essentially the same: 7-8 am: waking up and breakfast

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8 am – 12pm: walk in the gardens, treatment, baths, reading newspapers, writing letters, playing indoor games, amusements 12-2 pm: lunch 2-3 pm: resting 3-7 pm: work and amusements in the garden, treatment, baths, joint amusements and games 7-8 pm: supper and evening walk 9 pm: retreat to the apartments.101

If the weather allowed, snack and tea were served in the garden every morning and afternoon. Visiting was only possible with the permission of the director, on Wednesdays and Sundays from 11:00 am to noon and 3:00 pm to 5:00 pm. Visiting during meals and snacks was strictly forbidden (Fig. 3.3). Nurses oversaw patients night and day, in the rooms, the corridors and the gardens as well, and immediately notified the doctor in case of any irregular event or behaviour. According to the rules, the nurses always had

Fig. 3.3 Garden scene at Schwartzer’s Private Mental and Nerve Institution (Photo) (Babarczi Schwartzer, 1897)

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to be careful and quiet during their encounter with patients, and always had to act with “the greatest possible gentleness and indulgence” and “the verbal manifestations of indignation towards the patients entrusted into their care is severely punished.” Maids were forbidden to accept any presents from the mental patients, to take their letters or messages out of the institution, or to shop for patients without the permission of the doctor, even if the patients requested it. If violated, the offender would be dismissed.102 Work and amusements were central preoccupations that constituted part of the treatment. Due to the patients’ high social status, it is not surprising that an emphasis was placed on exercising the intellectual faculties. More educated patients spent much time on the study of history, the natural sciences, geography and the solving of puzzles and riddles, while most patients were expected to read and comprehend simpler texts. The propagation of intellectual occupation in the case of women was not specified in Schwartzer’s 1858 book, but a case presented by Bolyó in Gyógyászat (Medicine) suggests that women often exercised their minds with playing chess.103 Occasionally, intellectual engagement could be more controversial and potentially dangerous. Schwartzer’s assistant doctor, János Lyachovics published the case of a 26-year old male patient, the agronomist N.P.G., who was happy to play dominos and smoke with his fellow patients, read and draw, and who “nicely conversed about agronomy, including practical details.”104 But he was gripped by the delusion that he was Socrates, and “world-shaking thoughts burned his brain.” When agitation approached, he asked for paper and pen, and began to put down his “splendid thoughts with great enthusiasm.” As Socrates, he wrote about Drakon, and Solon’s republic as well as about the purpose of the world. Lyachovics’s account exposes the patient as much as the doctor himself. That Lyachovics devoted several long paragraphs to discuss N.P.G.’s thoughts about the soul reveals his own enthusiasm as well. Upon his discharge as cured after nine months, N.P.G. was nonetheless given the advice that he should occupy himself with field work, read as little as possible, and drink mineral water specifically from the Buda region.105 Male patients in the asylum occupied themselves with gardening, while women only did light works in the garden, like cleaning of the paths, picking fruits and watering. Women also did usual female tasks, like rending, plucking, needlework, reeling, knitting and the cleaning of furniture, rooms and cloths. This work-division reflected traditional gender

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norms but clearly trespassed class-divisions. Schwartzer claimed that he allowed relative freedom for the patients in their choice of work, there was no coercion. He also laid emphasis on industriousness and made sure that patients of all social status took part in the cultivation of the gardens.In his view, it was tantamount to “strengthen domestic virtues and increase … contentment within the more genteel.”106 In spite of his egalitarian views, it is difficult to imagine aristocratic ladies immersed in the picking of fruit or furniture cleaning. In reality, occupational activities probably did vary according to social standing. Much stress was laid on amusements as well. Most men enjoyed playing cards, dominos, chess, draughts and skittles, while women listened to music and played instruments, and all patients could take part in theatrical plays and excursions.107 The psychic tools of order, work and amusements were in practice combined with the above-detailed physical treatment. The case of Katalin N., a 40-year old wife of an artisan, published by Schwartzer’s assistant doctor, Károly Bolyó108 demonstrates this. After Katalin N. murdered her 5-month old child, she was pronounced to be mad, suffering from religious melancholy and hallucinations. Her treatment was both “medical and psychic,” the first aimed at increasing her metabolism and the function of her bowels with medication, and fighting insomnia with opium, which also positively affected her mood. The opium was given in “cure cycles,” a few days increasing, then decreasing doses, followed by a few days pause, over and over again for six weeks. She was also assigned long walks in the garden, and a cold “rain” shower every three days. Psychic treatment consisted of introducing order and cleanliness into her life and diverting her attention from her crime. Her needs of “noble entertainment” like music and chess were satisfied. Bolyó emphasised that “the doctor’s authority had to be bolstered,” while the patient was kept under “constant surveillance.” The woman was claimed to have been completely cured of her disease.109 Doctor and Patient In Schwartzer’s idea of the therapeutic asylum, the asylum provided a parallel universe, a new family for the insane. Hence, it was of paramount importance that the doctor lived with his patients. The director-chief doctor’s flat was in the building for the male patients, and his assistant doctor lived in the women’s ward.110 The insane were seen as children

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and mental illness was a “condition that resembles childhood, the early exaggerated conditions of childhood.”111 At the centre of the family stood “the doctor, who governs everything in the institution, who knows about everything, frequently sees his patients, and has a beneficial influence on them … who is the spirit of the institution” (95). Like the pater familias, he ruled over the household as an authoritarian, charismatic figure who imposed discipline and control over his patients. “The doctor has to impose punishments, but also has to give rewards.” He had to be the patients’ “benevolent protector,” his speaking “consoling, … friendly, but serious,” flowing from “a good heart” (122–123). With their admission to the asylum, patients were thus treated as (ideally) obedient children, greatly exposed to their doctor (93). The doctor’s art consisted of mastering control over the patient’s psyche and manipulating fear without resorting to physical coercion. As Schwartzer explained, “the fearless and courageous” patients had to be “tamed, and our vigilance can practice … such a power over them, that they become intimidated and tremble, and yield to those who are skillful enough to demonstrate power before them.”112 Against their anger, we have to set great visible power, which convinces them that any opposition is useless, and thus they will obey; but we only resort to this if we were otherwise forced to use coercion. We must never treat the patient badly, since that humiliates him; and deprived of his dignity, he is greatly angered, and his raging anger is itself mania. … Despotic punishments, long locking up, chains, hits, rough words, threats, all just excite the patient instead of calming. If strictness is necessary, it must be practised without hastiness and crudeness, otherwise the patient will perceive only ill will in all the actions of those surrounding him. (122–123)

The doctor’s charisma was supposed to substitute physical coercion (or rather, physical coercion was substituted by a form of psychic coercion)113 and Schwartzer was praised for introducing no-restraint in his asylum, an ideal professed by many of his assistant doctors who subsequently became directors and head doctors at large public asylums.114 Although Schwartzer stated that the institution refrained from anything that would increase the pain or fear even in the most restless patients, he admitted the use of the straitjacket, but only in the most extreme

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cases. Lyachovics described the case of S.E., a 19-year old Jewish shopassistant who suffered from mania, and who was screaming night and day for 10 days “during which he was of course kept in straitjacket, tied to the bed.” Lyachovics mused disbelievingly over how the English could apply the no-restraint system with their raging and destructive patients. Bolyó reported the case of a female patient who was calm at the admission and first observation, but after the doctor left, she turned into raging madness and attacked a nurse, tearing off the nurse’s cloths and beating her up, until the nurses could put the straightjacket on her. Understood as suffering from mania, the patient was subsequently tied to her bed, was isolated and forcefully fed with special tools, “the most difficult and unpleasant, but necessary procedure” in the field, Bolyó conceded.117 Doctors in fact probably regularly resorted to some form of physical coercion. Another aspect of the doctor-patient relationship was their competition for outwitting each other. From the doctor’s point of view, it was therapeutic, from the patients’, it was necessary for getting along in an asylum. Lyachovics for instance reported about a “hawk-nosed, thick-bearded, good looking,” 32-year male patient, D.D. who was “the living embodiment of sarcasm,” to whose mockery the entire staff, doctors, nurses and patients were exposed. His bodily functions were unimpaired, but he was suffering from insomnia, and olfactory sensorial errors that led to hallucinations and persecutory mania. He apparently had a great need for self-expression, which the asylum did not always allow. He painted puzzles on the walls and composed music. When the doctor took D.D.’s candles to prevent his late-night composing, D.D. produced candles for himself. “The mad are masters in such things, they carry out their plans with the greatest skill and perseverance and can outwit even the shrewdest person.” When his pencil was taken away, he collected used matches, gathered the soot from the ends, and continued drawing, until he promoted himself as a poet. His dedication was so great that, that within a year, he filled 200 sheets of paper with Latin, Hungarian, German and Serbian poems, full of sarcasm and “Weltschmerz.” About three weeks after D.D. was taken home uncured, Lyachovics was surprised to read some of D.D.’s poems— produced at the asylum—in a popular daily newspaper and signed by D.D.’s pseudonym used in the institution. The poor author subsequently had to face greatly unsatisfied criticism in the editorial columns.118 Lyachovics claimed that doctors also often had to “outsmart” or rather, to behave “according to the patient’s logic” in order to achieve

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a successful treatment. He quotes an example of his former teacher in Prague, L. Fishl. A melancholic patient in the Prague lunatic asylum was only willing to eat food he stole from his fellow patient, since he had the delusion that he had no money but had to pay for the food. Thus, the doctor ordered double portion for the other patient so that the melancholic can steal his share (86). The doctor had to be patient, and “choose the right moment,” after ample consideration. One of Lyachovics’s patients was not willing to take the tranquilliser; neither rational argumentation, nor continuous frightening worked, until once the patient asked the doctor: “Wer befiehlt es?” (“Who ordered this?”) When Lyachovics quietly answered, “der Kaiser!” (“the King”), the patient eagerly swallowed the medication (87). The skillful manipulation of the patient was regarded as a form of treatment in the Schwartzer asylum, for example the patient who dreaded money was nevertheless ordered by the doctor to buy bread rolls.119 In the treatment of certain forms of mental disorder, Schwartzer suggests that “we should resort to surprise and smartly designed vexations which fit the patient’s conditions and which only the doctor is able to define.” Elsewhere he states that “the attention of these patients sometimes can also be grasped if we surprise and astonish them, some interesting and unexpected scene … may bring them back to their reason.”120 Ferenc Schwartzer’s enterprise was continued by his son, Ottó Babarczi Schwartzer (1853–1913), who received his medical degree at the Budapest Medical Faculty in 1877, gained his knowledge of mental illnesses by his father’s side and eventually took over directing the institute. In 1912, an announcement advertised Babarczi Schwartzer’s institute as “a Sanatorium for nervous patients.”121 The wording on the one hand nicely illustrates the duality of innovation and tradition. The asylum was keeping up with recent trends of the turn of the century when it offered catering for nervous patients at the “age of nervousness.” But rather than enticing clients with long lists of different water and electro-therapies as other nerve sanatoria would do, at the centre of Babarczi Schwartzer’s advertisement we can still see the towering figure of the charismatic doctor who still represents the “old-type of alienist,” who “follows in the footsteps of his father,” who is “the doctor of the body and the soul,” “from whose noble head, authority and goodness radiates. His friendly eyes evoke trust in those entrusted to his care, although with a single look, he can penetrate to the most hidden secrets of his patients” (156).

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Conclusion: The Schwartzer Psychiatric Enterprise While in many Western countries the competence of alienists in treating the insane was under continuous and serious attacks from general physicians, laymen and the church, in Hungary Schwartzer managed to successfully bolster the professional status of the first lunatic asylum in different ways. The private asylum’s professed purpose, carefully designed basic regulations and admission procedures radiated medical professionalism. Schwartzer’s complex theory of mental illness proved his comprehensive expert knowledge informed by different influential medical, neurological and psychological traditions of the period: a form of humoral pathology embraced in Viennese and Pest medical circles, Enlightenment dynamic-vitalism and neurology and Romantic psychiatry. With the combination of these traditions, Schwartzer managed to reconcile oppositions between organicist and psychological approaches. Schwartzer’s idiosyncratic and eclectic theory reflects a remarkably holistic view of the human being complemented with a refined psychology, where organs and physical processes, the workings of the nervous system, mental functions, sensations and moods/feelings were closely connected. Such an expertise certainly surpassed that of the general physician. In terms of treatment, it was moral therapy that provided the strongest legitimacy for the therapeutic asylum. The separation of the patient from his or her usual environment and seclusion in a special institution among his kindred, as well as the power of order and clear reasoning were seen as effective in the treatment of the insane. Moral therapy carried the values of bourgeois society and the asylum community mirrored familial hierarchy. The doctor posed as a patriarchal figure while the patient was seen as a child into whose life the doctor (re)introduced order and discipline. Mental illness was understood as a childlike state, and treatment consisted of a mastery of control over the deluded childish psyche and a manipulation of fear. The doctor-patient relationship was characterised by an uneven power-relation, the patient’s great exposure to the doctor. Schwartzer’s role and influence was outstanding in the history of Hungarian psychiatry. His book remained the only comprehensive textbook until the end of the 1880s, and his students, Károly Bolyó, Gyula Niedermann, Károly Laufenauer, Jen˝ o Konrád, Károly Lechner, and his son Ottó Babarczi Schwartzer later became important figures and holders of high positions within Hungarian medical and psychiatric

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circles. These people, who gained their primary professional experience at the Schwartzer private asylum, became the first medical staff of Lipótmez˝ o National Lunatic Asylum, the first lecturers in psychiatry at the Medical Faculty, and directors of subsequently established asylums and psychiatric hospital wards. Through his students as intermediaries, many of Schwartzer’s ideas and practices were transported to public asylums and psychiatric hospital wards established from the 1860s. The next chapter discusses the extent to which Schwartzer’s ideals of individualised care, moral treatment and non-restraint could be implemented in these new institutions.

Notes 1. For data concerning Ferenc’s ancestors, I used Nándor Horánszky’s short book entitled A Schwartzer-család a magyar tudományos életben (The Schwartzer Family in Hungarian Scientific Life: Bibliography) (Budapest: Plantin Kiadó, 2000). 2. One of his works was entitled A bor, mint Ausztria és Magyarország sarkalatos kérdésér˝ol (On Wine, as the Fundamental Question of Austria and Hungary). See Horánszky (2000), 4. 3. See Anna Szabó Gordosné, “Schwartzer Antal és Károly gyógypedagógiai tevékenysége” (The Activities of Antal and Károly Schwartzer in the Field of Special Education), Gyógypedagógiai Szemle (Special Education Review) 4 (1979): 287–294; Horánszky (2000), 6–8. 4. Horánszky (2000), 9. On Ferenc Schwartzer, see János Kenéz, “Schwartzer Ferenc, a modern hazai elmegyógyászat úttör˝ oje” (Ferenc Schwartzer, Pioneer of Modern Hungarian Mental Health Care), Orvosi Hetilap (Medical Weekly) 28 (1969): 1629– 1632; “Ferencz Schwartzer” entries in József Szinnyei, Magyar írók élete és munkái (The Life and Work of Hungarian Writers), Vol. 12 (Budapest: Saád-Steinensis, 1908), 745–746; Révai Nagy Lexikona (Révai Big Lexicon), Vol. XVI (Budapest: RacineSodoma, 1924), 682; and Magyar Életrajzi Lexikon (Hungarian Biographical Lexicon), Vol. 2 (Budapest: Akadémiai Kiadó, 1969), 606. 5. See Gy˝ oz˝ o Zétény, A magyar szabadságharc honvédorvosai (Military Doctors in the Hungarian War of Independence) (Budapest: Egyetemi Nyomda, 1948), 118. After the bloody suppression of

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the War of Independence, the “magyarization” allowed by the “rebel” Hungarian government was withdrawn. 6. See Horánszky (2000), 18. 7. See Nándor Horánszky, “Schwartzer Ferencz javaslata 1848-ból az országos tébolyda ügyében (Adattár)” (Ferencz Schwartzer’s Recommendation Concerning the National Lunatic Asylum – Database), Az Országos Orvostörténeti Könyvtár Közleményei (Publications of the National Library for the History of Medicine) 29 (1963): 257–269. Ottó Babarczi Schwartzer claimed a crucial role for his father in the establishment of the Lipótmez˝ o National Lunatic Asylum, calling him “the real founder,” see Ottó Babarczi Schwartzer, Közigazgatási elmekórtan (Administrative Mental Pathology) (Budapest: Franklin, 1897), 209. See also: István Zsakó, “Az egykori Országos Tébolyda keletkezésének története” (The History of the Establishment of the National Lunatic Asylum), Az Országos Orvostörténeti Könyvtár Közleményei (Publications of the National Library for the History of Medicine) 4 (1956): 88–89. For his role in the foundation of the Angyalföld National Lunatic Asylum, see István Zsakó, ed., A budapesti angyalföldi Elme- és Ideggyógyintézet emlékkönyve, 1883–1933 (‘Memorial Book’ of the Budapest-Angyalföld Mental and Nervous Institute, 1833–1933) (Budapest: Attila-Nyomda Részvénytársaság, 1933), 15–19, 342–343. 8. From 1877 the asylum was directed by Ferenc’s son, Ottó Babarczi Schwartzer. Horánszky (2000), 28. 9. Alienist means asylum doctor throughout my text. 10. See also: Nándor Horánszky, “Schwartzer Ferenc és Schwartzer Ottó jelent˝ osége a magyar pszchiatria történetében” (The Importance of Ferencz and Ottó Schwartzer in the History of Hungarian Psychiatry), Az Országos Orvostörténeti Könyvtár Közleményei (Publications of the National Library for the History of Medicine) 15–16 (1959): 81–105. In the third generation: Ottó’s son, Ottó junior also followed in the steps of his father by becoming a psychiatrist. He emigrated to the United States in the 1920s where he died as a reputable psychiatrist. 11. In 1861, Ferenc Schwartzer requested and gained a privatdozent position to lecture in mental health and pathology at the Medical Faculty. See “Hírek” (News), Gyógyászat (Medicine) 17 (1861): 384; 30 (1861): 632; 41 (1861): 845. See also: Endre H˝ ogyes,

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ed., Emlékkönyv a Budapesti Királyi Magyar Tudományegyetem Orvosi Karának múltjáról és jelenér˝ol (‘Memorial Book’ on the Past and Present of the Medical Faculty of the Royal Budapest Hungarian University) (Budapest: Athenaeum, 1896), 208–209. 12. See Nándor Horánszky, “Schwartzer Ferencz” and “Schwartzer Ottó” in Az Országos Közegészségi Tanács kiemelked˝o orvos tagjai (1868–1893) (Eminent Doctors in the National Public Health Council, 1686–1893), ed. Lajos Varga (Budapest: Az Országos Orvostörténeti Könyvtár Közleményei, 1964), 235–246. 13. “Schwartzer Ferencz királyi tanácsos” (Ferencz Schwartzer Royal Councillor), Gyógyászat (Medicine) 13 (1872): 223. 14. See “Hírek” (News), Orvosi Hetilap (Medical Weekly) 24 (1884): 681. 15. On his death, see articles “Barbarczi Schwartzer Ferencz meghalt” (On the Death of Ferencz Babarczi Schwartzer), Gyógyászat (Medicine) 11 (1889): 129–130; Orvosi Hetilap (Medical Weekly) 10 (1889): 138. 16. See Horánszky (1964), 235–246. 17. See the list of greatest tax-payers in the capital in Imre Gúthi, ed., F˝ovárosi almanach, lexikon és útmutató. 1910–1912 (Yearbook, Lexicon and Guide to the Capital. 1910–1912) (Budapest: Légrády testvérek, 1912), 484. 18. The Schwartzer asylum’s contemporary Hungarian designations were “magántébolyda,” “magán˝ orülde” and “magán o ˝rült gyógyintézet” (“private lunatic asylum,” “private madhouse”). 19. László Epstein, “Magyarország elmebetegügye” (Mental Health Care in Hungary) Gyógyászat (Medicine) 38 (1897a): 582; Kálmán Pándy, Gondoskodás az elmebetegekr˝ol más államokban és nálunk (The Care for Mental Patients Abroad and in Our Country) (Gyula: Corvina, 1905), 383–384; and Ern˝ o Moravcsik, “A psychiatria fejl˝ odése hazánkban az utolsó 50 év alatt” (The Development of Psychiatry in Our Country During the Last 50 Years) Orvosi Hetilap (Medical Weekly) 1 (1906a): 39. 20. See József Pólya, Tudnivalók a Pesten felállított privát Elmekórintézetr˝ol (Information on the Private Mental Asylum Opened in Pest) (Pest: Házinyomda, 1842); Joseph Pólya, Bemerkungen und Statuten der zu Pesth errichteten Privat-Heilanstalt für Gemüths- und Geisteskranke (Pesth, Landerer und Heckenast, ˝ 1844); “Orjintézet Pesten” (Madhouse in Pest), Nemzeti Újság

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˝ (National Paper) 1841: 197; Pál Bugát, “Orjintézet Pesten” (Madhouse in Pest), Orvosi Tár (Medical Collections) (1841): 399; and Tamás Kun, “A pesti magán-elmekórgyógyintézetnek s eddigi m˝ uködésének rövid ismertetése” (Brief Account on the Pest Private Mental Asylum and Its Operation), Hírnök (Herald) 6 (1844): 34. See also: Lajos Nagy, Budapest története (The History of Budapest), Vol. III, ed. Domokos Kosáry (Budapest: Akadémiai Kiadó, 1975), 419 and György Gortvay, Az újabbkori magyar orvosi m˝ uvel˝odés és egészségügy története (The History of Hungarian Medical Culture and Health Care in Modern Times) (Budapest: Akadémia Kiadó, 1953), 133–134. 21. József Pólya, “Szellemkórok” (Mental Pathologies), Orvosi Tár (Medical Collections), 1839. 22. Bugát (1841), 399. 23. See: Nagy (1975), 419, and Gortvay (1953), 133–134. 24. See Pólya (1842); Pólya (1844). 25. Pólya (1842), 2. 26. Károly Bolyó, “A budai magán˝ orülde” (The Buda Private Madhouse), Gyógyászat (Medicine) 10 (1861a): 213–214. 27. It was built in Kékgolyó utca, on the estate of present-day National Oncology Institute. 28. Ferencz Schwartzer, A Budai Magán Elme- és Ideggyógyintézet tudósítója és tizenkét évi m˝ uködésének eredménye (Report on the Buda Private Mental and Nerve Institute and its 12-year Operation) (Buda: Ny. Bagó M, 1864), 2–6. 29. Ibid., 4–9. Pólya also required preliminary notification about relatives’ wish to take out patients yet uncured. Pólya also stressed that the asylum did not take responsibility for uncured patients taken home at an immature time. Pólya (1842), 4. 30. Schwartzer (1864), 2–9. 31. Ibid., 12. I discuss the detailed social and familial background of the patient population together with the two large public institutions of Lipótmez˝ o and Nagyszeben in Chapter 6. 32. Schwartzer (1864), 2–4. 33. Ferencz Schwartzer, A lelki betegségek általános kór- és gyógytana, törvényszéki lélektannal (The General Pathology and Treatment of Disorders of the Soul, with Forensic Psychology) (Budapest: Lauffler és Stolp, 1858), 98. 34. Schwartzer (1864), 4–9.

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35. Bolyó (1861a), 213–214. 36. See also Klára Brüll Engländer, Orvosok és kórházak Pest-Budán (Doctors and Hospitals in Pest-Buda) (Budapest, 1930), 93–94. She states that the asylum hosted 150 patients, which is probably wrong. 37. See Schwartzer (1864). 38. Schwartzer (1858), 22. 39. János Lyachovics, “Könyvismertetés: Schwarzer Ferenc: A lelki betegségek általános kór- és gyógytana” (Book Review: Ferenc Schwartzer, General Pathology and Treatment of Psychic Disorders), Orvosi Hetilap (Medical Weekly) 29 (1858): 460. 40. For the doctrine of old humoral pathology, see Roy Porter, The Greatest Benefit to Mankind. A Medical History of Humanity from Antiquity to the Present (London: HarperCollins, 1997), 9, 154; for humours in Greek medicine: 56–60. 41. For humoural pathology and insanity, see: Roy Porter, Madness. A Brief History (Oxford: Oxford University Press, 2002), 36–43. 42. Roy Porter, Mind-Forg’d Manacles. A History of Madness in England from the Restoration to the Regency (London: Penguin Books, 1987), 176. 43. For Willis, see Porter (1987), 178; Porter (1997), 221, 229, 242–243. 44. Porter (1997), 246. 45. See Porter (1997), 247, 245–254, 258–263; Porter (1987), 176– 179. 46. See Erna Lesky, The Vienna Medical School of the 19th Century, trans. L. Williams and I. S. Levij (Baltimore, London: Johns Hopkins University Press, 1976), 8–10. 47. Porter (1997), 262, 314; Porter (1987), 179–180; Lesky (1976), 8–10. 48. See Porter (2002), 127–128. 49. For Romantic psychiatry, see Otto Marx, “German Romantic psychiatry,” History of Psychiatry 4 (1990): 351–380; 1 (1991): 1–26; Porter (2002), 139–143; Edward Shorter, A History of Psychiatry from the Era of the Asylum to the Age of Prozac (New York: Wiley, 1997), 29–32, 72, 74. 50. For related literature concerning Hungary, see Gy˝ oz˝ o Birtalan, “A felvilágosodás mentálhygiénéje külföldön és Magyarországon” (The Enlightenment’s Mental Hygiene in Hungary and Abroad),

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Az Országos Orvostörténeti Könyvtár Közleményei (Publications of the National Library for the History of Medicine) 102–104 (1983): 45–75; József Antall, “Gesundheitliche Aufklärung und Gesundheitserziehung in Ungarn im 18–19. Jahrhundert,” Az Országos Orvostörténeti Könyvtár Közleményei (Publications of the National Library for the History of Medicine) 86 (1979): 25–37; Gy˝ oz˝ o Birtalan, “Személyi egészségvédelem és mentálhygiéne a 18. században” (Personal Health Care and Mental Hygiene in the 18th Century), Orvosi Hetilap (Medical Weekly) 10 (1982): 607–610. 51. See also discussed in Chapter 1. 52. Lesky (1976), 4. 53. See these aspects discussed in Chapter 1. See the chapter “Scientific Medicine in the Nineteenth Century” in Porter (1997), 304–348 and William F. Bynum, Science and the Practice of Medicine in the Nineteenth Century (Cambridge: Cambridge University Press, 1994). 54. See discussed in Lesky (1976), 24–30. 55. For the Viennese situation, see Lesky (1976), 30–35. 56. For mesmerism and animal magnetism in France and elsewhere, see Robert Darnton, Mesmerism and the end of the Enlightenment in France (Cambridge, MA: Harvard University Press, 1968); Adam Crabtree, From Mesmer to Freud. Magnetic Sleep and the Roots of Psychological Healing (New Haven: Yale University Press, 1993); Anne Harrington, “Hysteria, Hypnosis, and the Lure of the Invisible: The Rise of Neo-Memerism in Fin-de-Siecle French Psychiatry,” in The Anatomy of Madness. Essays in the History of Psychiatry, Vol. 3., eds. William Bynum, Roy Porter, and Michael Shepherd (London: Tavistock, 1988a), 226–246. 57. For homeopathy and hydrotherapy in Vienna, see Lesky (1976), 30–35; for Hungary, see József Antall, “Homeopathy and Medical Education in Hungary,” Az Országos Orvostörténeti Könyvtár Közleményei (Publications of the National Library for the History of Medicine), 51–53 (1969): 99–114; Gortvay (1953), 100–102, 265–266, 281; Gedeon Borsa, “Argenti Döme (1809– 1893),” Az Országos Orvostörténeti Könyvtár Közleményei (Publications of the National Library for the History of Medicine), 30 (1964): 137–150. 58. See Lesky (1976), 35–42, 42–52, 59–75, 78–86.

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59. Ibid., 70–72. 60. On Lenhossék, see Gortvay (1953), 21–25, 82–84, 119–120; Lesky (1976), 72–73. 61. See Mihály Lenhossék, Physiologia medicinalis, Vol. II (Pestini, 1816–1818): 326, quoted in Lesky (1976), 73. 62. See Mihály Lenhossék, Darstellung der menschlichen Leidenschaften (Pesth, 1808); republished in revised forms: Darstellung des menschlichen Gemüths in seinen Beziehungen zum geistigen und leiblichen Leben (Wien, 1824) and Darstellungen des menschlichen Gemüths (Wien, 1834). 63. Mihály Lenhossék, “Az Állati Magnetismus rövid rajzolatja” (A Brief Outline of Animal Magnetism), Tudományos Gy˝ ujtemény (Scientific Collections), 1 (1817) 10: 3–41. 64. Lesky (1976), 81, on Hartmann, see 78–86. 65. See his significance in reforming Viennese medical research below, in Chapter 4. 66. See Porter (1997), 330–331 and Lesky (1976), 111, 106–117. 67. For more on them, see Chapter 2. 68. Illnesses counted as predisposing factors. In Schwartzer’s understanding, any disease, disordered organ or bodily function may lead to mental illness due to the close relationship between body and mind. Thus, the alienist is supposed to be a good general doctor as well, an idea that is generally held throughout the period observed. Schwartzer (1858), 57. 69. See Etienne Esquirol, Des maladies mentales (Bruxelles, 1838), especially volume 1. 70. Schwartzer (1858), 45–46. 71. I discuss degenerationist thinking and the pervasiveness of the idea of “nervousness” in Hungarian literature in Chapter 8. 72. Schwartzer (1858), 47. 73. See discussion of phrenology in Chapter 2. 74. For a book based on Gall’s phrenology and published around the time of Schwartzer’s work, see: Jen˝ o Szárics, Lélektan az agytani rendszer nyomán (Psychology Based on the Study of the Brain) (Szabadka, 1848). 75. See Anne Harrington, Medicine, Mind, and the Double Brain. A Study in Nineteenth-Century Thought (Princeton: Princeton University Press, 1987), 35–105.

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76. See Károly Laufenauer, El˝oadások az idegélet világából (Lectures in the World of Nerve-Life) (Budapest: Királyi Magyar Természettudományi Társulat, 1899a); Miklós Dubay, “Észrevételek Laufenauer és H˝ ogyes ‘A hypnotismusról’ tartott el˝ oadásukra” (Remarks on Laufenauer and H˝ ogyes’s Lecture on ‘Hypnotism’), Gyógyászat (Medicine) 12 (1884): 197. 77. Scholarship in this field is too rich to enumerate, therefore I single out a few classic works. On gender categories in medical and scientific writings, see Emily Martin, The Woman in the Body. A Cultural Analysis of Reproduction (Boston: Beacon Press, 1987), Evelyn Fox Keller and Helen E. Longino, eds., Feminism and Science (Oxford: Oxford University Press, 1996) and Barbara Duden, The Woman Beneath the Skin: A Doctor’s Patients in Eighteenth-Century Germany (Cambridge, MA, and London: Harvard University Press, 1991). On the history of different medical models of sexual difference, see Thomas Laqueur, Making Sex. Body and Gender from the Greeks to Freud (Cambridge, MA: Harvard University Press, 1990). On metaphors in science, see Evelyn Fox Keller, Refiguring Life: Metaphors of Twentieth-Century Biology (New York: Columbia University Press, 1995). 78. Schwartzer (1858), 49. 79. See more on the changes in taxonomy in Chapter 7. 80. Schwartzer (1858), 53–54. 81. See Ern˝ o Moravcsik, A gyakorlati elmekórtan vázlata (Outline of Practical Psychopathology) (Budapest: Franklin Társulat, 1888); Jakab Salgó, Az elmekórtan tankönyve (Textbook of Mental Pathology) (Budapest: Franklin Társulat, 1890); and Ern˝ o Moravcsik, Gyakorlati elmekórtan (Practical Psychopathology) (Budapest: Magyar Orvosi Könyvkiadó, 1897). 82. Schwartzer (1858), 51–52. 83. See discussed in detail in Chapter 5. 84. Also see discussed in Chapters 5 and 8. 85. Schwartzer (1858), 52. 86. See discussed in Chapter 8. 87. Like in cases of debauchery and self-pollution, see ibid., 73. 88. Psychic state has a strong connection with breathing: a person in love has a “fuller” breath, “a suitor’s deep breaths turn

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into yearning,” anger and mad raging requires more energetic breathing, etc. See ibid., 82. 89. Detailed inspection of the hair, its condition and greasiness, and even the direction of its fall are assumed to reveal the mental state. In case of certain diseases of the brain, black hair turns red, the blond hair turns paler, sometimes woolly or silky, Schwartzer adds. Ibid., 12. 90. János Lyachovics, “Töredékek a budai magán o ˝rüldéb˝ ol” (Fragments from the Buda Private Madhouse), Orvosi Hetilap (Medical Weekly) 12 (1857): 183–189; 13 (1857): 200–202; 4 (1858): 54–58; 6 (1858): 85–88. 91. Károly Bolyó, “Az o ˝rüldébe utasított elmebetegek kórrajzának készítési módja” (The Mode of Writing Case Histories on Mental Patients in Lunatic Asylums), Gyógyászat (Medicine) 33 (1862a): 676–679. 92. Ottó Babarczi Schwartzer, A Budai Magán Elme- és Ideggyógyintézet értesít˝oje (Report of the Buda Private Mental and Nervous Institute) (Budapest: Hornyánszky Viktor, 1894), 8–12. 93. For the therapeutic management of time, space, and the moving of the patients between wards at the Illenau asylum, see Cheryce Kramer, A Fools’ Paradise. The Psychiatry of Gemüth in a Biedermeier Asylum (Doctoral dissertation, The University of Chicago, 1998). 94. Schwartzer (1858), 95. 95. Ibid., 93. 96. Bolyó (1861a), 257–259. 97. Schwartzer (1858), 93–95. 98. Schwartzer’s assistant doctor, Lyachovics (1857), 187. 99. Schwartzer (1864), 9. 100. Lyachovics (1857), 187. 101. Since I did not find an “order of the day” published by Schwartzer, I use his son’s account from 1894. See Schwartzer (1864), 15–16. For the same Report in German, see Ottó Babarczi Schwartzer, Prospect der Privat-Heilanstalt für Gemüths und Nervenkranke zu Budapest (Budapest: Druck von Viktor Hornyánszky, 1897). 102. Schwartzer (1864), 7. 103. Károly Bolyó, “Tudósítás Schwartzer tanár budai magán˝ orüldéjéb˝ ol” (Reports from Schwartzer’s Buda Private

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Madhouse), Gyógyászat (Medicine) 17 (1861b): 348–352; 26: 558–559, 578–579, 348–352. 104. Lyachovics (1858), 85–88. 105. Lyachovics’s account also mentions treatment for the patient’s bodily ailments: for his intermittent fever, and the pneumonia he contracted at the institute. The doctor briefly states that the patient was cured of these illnesses and “at the same time recovered from his mental affliction.” See ibid. 106. Schwartzer (1864), 9. 107. Schwartzer (1858), 97. 108. From the appearance of the medical weekly Gyógyászat (Medicine), Bolyó energetically began to publish cases from the Schwartzer asylum where he was working as an assistant doctor. 109. Bolyó (1861b), 348–352. 110. Schwartzer (1864), 91. 111. “The mentally disordered person easily believes like a child but is not careful and is quite jealous; he does not consider his acts and their consequences. For this reason, the mentally disordered person cannot be accountable before the law, and thus usually defined as a minor.” See Schwartzer (1858), 23. 112. “The attention of raging mad people cannot be fixed, in order to make them hear and follow reasonable propositions. The essence of psychic healing is to gain mastery over [the patients] attention, govern their rationality, and gain their trust.” “Fear … makes them willing to listen and follow the given advice.” Ibid., 122–123. 113. See similar interpretation in Michel Foucault, Madness and Civilization. A History of Insanity in the Age of Reason, trans. Richard Howard (London: Routledge, 1992 [1961]), 241–279. 114. For a deeper discussion of restraint (physical and chemical), see Chapter 4. The Lipótmez˝ o National Lunatic Asylum was built with dark isolation cells and was equipped with different restraint tools. At the opening of the asylum, Schwartzer’s previous assistant doctor, Károly Bolyó is claimed to have immediately discarded them. The use of straitjacket was in practice but had to be ordered by the doctors. In 1884 Gyula Niedermann, another of Schwartzer’s assistant doctors, terminated their use. Niedermann avoided the frequent use of the dark cells, which were eventually closed and rebuilt to serve different functions

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by Jen˝ o Konrád in 1906. See Pándy, 1905, 369 and János Fekete, “Intézetünk megalapítása, és m˝ uködése 1900-ig” (The Foundation of Our Institute and Its History until 1900), in Az Országos Ideg- és Elmegyógyintézet 100 éve (Hundred Year Anniversary of the National Institute for Nervous and Mental Diseases), ed. Zoltán Szabó, Zoltán Böszörményi and Mária Kuntner (Budapest: Országos Ideg- és Elmegyógyintézet, 1968), 67–83, 73, 74, 77. In large public asylums, the no-restraint system was recommended by the Interior Ministry only in 1900. See Ministry of Interior, Magyarország elmebetegügye az 1900. évben (Mental Health Care in Hungary in 1900) (Budapest: Schmidl Sándor Könyvnyomdája, 1901), 11. 115. Schwartzer (1864), 9. 116. Lyachovics (1858), 85–88. 117. Bolyó (1861b), 558–559, 578–579. 118. Lyachovics (1858), 57. 119. Lyachovics (1857), 187. 120. See Schwartzer (1858), 130, 122–123. 121. Gúthi (1912), 156.

CHAPTER 4

The Kingdom in Miniature: Public Mental Asylums from the 1860s

The colossal building with its seemingly infinite rows of windows at the corner of the valley leans with its back to the forest-covered mountains stretching behind; from the heightened terrace, its facade proudly looks down on the valley and, beyond it, on the double town,1 as if it wanted to say: “what the defective machine of your social life muddled up, I put in order.”2

This chapter captures the nineteenth-century milieu of public asylum life by focusing on doctors, patients and practices. It deals mostly with Lipótmez˝ o Royal National Lunatic Asylum and reconstructs different aspects of life and treatment within its walls. Through introducing Lipótmez˝ o’s five directors in the period between 1868 and 1920, I first discuss asylum space, treatment, nursing, patient occupations and questions of escape and the use of coercion and restraint. Then, as a result of a systematic study of contemporary legal regulations of mental health issues, I juxtapose the ideal of admission, discharge and guardianship proceedings with the actual practice in asylums and hospital psychiatric wards. After its establishment, Lipótmez˝ o Royal National Lunatic Asylum3 gave rise to powerful metaphors in psychiatric writings as well as in the public imagination.4 Whether only in the asylum director Gusztáv

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 E. Lafferton, Hungarian Psychiatry, Society and Politics in the Long Nineteenth Century, Mental Health in Historical Perspective, https://doi.org/10.1007/978-3-030-85706-6_4

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Fig. 4.1 Front picture of the Buda State Mental Asylum (Lipótmez˝ o) (Graphics) (Source Lipót Grósz, Emlékirat a hazai betegápolási ügy keletkezése, fejl˝odése, s jelenlegi állásáról , különös tekintettel a betegápolási költségekre [Memoir Concerning the Birth, Development and Present State of Our National Patient Care] [Buda: Magyar Királyi Egyetemi Nyomda, 1869])

Oláh5 ’s memories, or truly, as he claims, in the wider public imagination, Lipótmez˝ o appeared after its emergence as a “medieval abbey at the heart of the valley,” like Pannonhalma,6 in the court of which the Swabian population of the area received employment, and whose pharmacy provided medication for its neighbourhood for all kinds of diseases.7 The asylum itself, “with its monastery-like order, cleanliness and discipline,” was “the instrument in healing the disordered mind.”8 The idea of the asylum as a therapeutic means was thus embraced in the abbey metaphor with its medieval and monastic connotations (Fig. 4.1). The quotation at the beginning of this chapter from an 1869 article in the highly popular weekly Vasárnapi Újság gives a similar image of the personified asylum that reigns over its surroundings. In both the medieval abbey metaphor and the image of the institution that repairs what society has damaged, ideas of seclusion and distance from society prevail: the

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institute forms a world of its own and fulfils religious, medical or social remedial functions. In late nineteenth-century accounts by psychiatrists and social commentators, the opening of the public asylum was hailed as the beginning of modern mental health care in the country. It also became a symbol of national independence and civilised statehood. Its opening just a year after the 1867 Compromise between Hungary and Austria9 was strongly connected to the recent constitutional triumph of the country: this “first great achievement of independent statehood” was seen as an “unproductive institution standing for civilisation,” luxuriously decorated with a large coat of arms and the crown (although it was originally planned with the two-headed eagle) and likened to “the seat of the country’s highest political authority.”Lipótmez˝ o came to embody independent national existence and pride and was seen as a pledge for development in mental health care.11 In the light of these retrospective claims marked by their triumphal tone and nationalist sentiments, certain facts almost disappear or get abstracted. Lipótmez˝ o was planned on Viennese model during the period of “Austrian domination” by the Viennese architect Zettel and with the professional advice of Joseph Gottfried Riedl.12 The Czech Riedl was the director of the Imperial Royal Institution for the Treatment and Care of the Insane designed for 700 patients and opened in Bründlfeld (Vienna) in 1853, an institute considered modern at the time with its surrounding large parks and its spaces for occupational therapy.13 However, soon after its opening, there were critical voices attacking Lipótmez˝ o from both professional and nationalist perspectives. From the experts’ point of view, Lipótmez˝ o’s block-system was soon denounced as outdated in comparison to the more modern pavilion system, and the coercive tools it was equipped with were condemned as medieval and inhuman.14 From a nationalist and professional point of view, Hungarian psychiatrists felt offended that no Hungarian expert took part in the planning. Several critics attacked the builders of the institution for not consulting experts before designing the building and its equipment,even though Riedl was regarded as Austria’s foremost institutional expert.16 Lipótmez˝ o’s ground plan (Fig. 4.2) reflects a remarkably symmetrical and closed architecture of a huge one-block building with a large chapel in the centre, and with inner courts secluded from the outer world.17 At the front wing of the building, the main entrance protrudes to receive patients and their visitors. This side of the building accommodates the

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Fig. 4.2 Ground-plan of the Buda State Mental Asylum (Lipótmez˝ o) (Graphics) (Source Grósz, 1869)

director and the doctors who lived on the first and second floors. On the massive columns above the entrance is a huge terrace belonging to the council-room, which also served as the director’s study and consulting room. The patients were placed in the building along three axes. A clear division immediately visible in the ground plan is according to sex: the right-wing accommodated the male department and the left the female. The second axis runs from the front to the back and shows an increasing degree of the patients’ restlessness. The calmest patients were placed in the front side. Moving towards the back, one came across more agitated patients, and at the back wing, with the windows facing the woods, were the rooms of the raging (“dühöng˝ o”). This wing contained 64 small isolation cells with artificial light and without windows. It was as if the asylum had wished to show its most normal face towards visitors, while attempting to hide the unruly from the public eye; to keep quiet towards the main road and have the woods up on the hill behind the building take up the cries and shouting of the mad.

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The third axis along which patients were placed was according to their financial situation. First and second-class paying patients were placed on the first floor in rooms for 1–3 patients, richly and conveniently furnished (with curtains, carpets, plants, pictures, a piano, a billiard table, etc.). Patients paying the third-class rate or kept at public expense were placed in barren rooms for 10–12 people, furnished only by wooden seats, tables and simple wooden beds on the ground floor and the second floor.18 Rather than following a vertical separation of the poor from the wealthier, the two floors of the poor surrounded the first floor of the rich. At the heart of the building stands the Roman Catholic chapel, surrounded by spaces designated to satisfy other patients’ religious needs: the Israelites to the right, the Greek Orthodox to the left, and the Lutherans and Calvinists on the first floor.19 The central position of the chapel symbolically expresses the importance of the patients’ spiritual needs as well as their communal feeling where no social or gender aspects divide the population.20 The corridors of the building are wide, light and spacious. Originally, there were two large common baths21 opening from the cross-corridor of the Chapel on the ground floor, the male on the right, the female on the left. They served daily hygienic needs.22 The water was supplied from the wells of the asylum, pumped into water basins on the attic, and then circulated over the asylum’s own water-system.23 The modern fittings of the institute filled commentators with pride. In his article, Zombory enthusiastically reported that the asylum had “orderly bathrooms and splendid water-system, etc., that is, every conceivable comfort and neatness.”24 Captivated by the “neat bath and the steam-bath department,” the author of the article in Vasárnapi Újság also stated that “nothing reminds us that we are in a lunatic asylum; so far we have found no trace of coercion or restraint, just the opposite, everywhere the greatest comfort is provided in order to make the patient feel well.”25 The building—a functioning psychiatric institute until 2007—was surrounded by beautiful parks designed by famous gardeners. Some of the parks were separated for the agitated patients.26 Behind the building, on the slope up on the hill, was a forest whose territory was twice as big as that of the asylum and the surrounding parks. Towards the gate of the main entrance stood the house of the gardener and the lower reception desk.

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Asylum Life Under Four Directors, 1868–1920 Life Conditions, Nursing and Treatment Lipótmez˝ o had five directing head physicians during the observed period: Emil Schnirch (1868–1884), Gyula Niedermann (1884–1899), Károly Bolyó (1900–1905), Jen˝ o Konrád (1905–1910), and Gusztáv Oláh (1910–1925). As a rule, all five travelled widely in Europe visiting foreign asylums. Except for Schnirch and Oláh, they studied at the Medical Faculty in Budapest and had their first encounters with mental patients at Schwartzer’s private asylum. Oláh got his doctoral diploma in Vienna and started to work at Lipótmez˝ o in 1881 as a doctor. Born in 1822, Schnirch (1822–1884) came from a wealthy and prestigious Buda family with good connections to the Viennese court: his father was the personal secretary of Empress Mária Ludovica.27 After his secondary school years in Buda, he received his medical diploma in Vienna in 1846, and for four subsequent years was trained as an obstetrician and surgeon. He worked at the mental ward of the Lazareth hospital in Vienna for three years. He was a good friend of Alexandre Bach,28 Austrian minister and culture politician of neo-absolutism, at whose encouragement Schnirch became the chief physician of Borsod county in Hungary in 1853. He was active in the foundation of Miskolc public hospital. In 1860, he visited German, French, English and Belgian asylums on state money, then worked at the health department of the Interior Ministry and became the first director of the Nagyszeben Royal National Lunatic Asylum in Transylvania in 1863. He left that post five years later and became the director of Lipótmez˝ o in 1868. In 1879, he became a Royal Councillor.29 Schnirch appears in Oláh’s memories as a conservative, traditional gentleman who practised the science of mental pathology as it was “usual at the time among gentlemen.” Schnirch had a large private library and subscribed to (presumably German) journals, but did not regard writing important in the case of asylum doctors: he valued “clear sight of the doctor refined through his own experience.”30 Although he published a few casuistics in German journals, apart from a short article on “pyromania” in the Orvosi Hetilap (Medical Weekly) in 1860, I found literally nothing produced by him in Hungarian medical journals. Also, no books, and more curiously, hardly anything on him in nineteenth-century accounts: his significance somewhat fades compared to subsequent directors.

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He seems to have been something like a cuckoo’s egg in the nest of early Hungarian psychiatry. He could have been questionable both politically and professionally. His friendship to the despised Bach might have contributed to his appointment to Nagyszeben, but also to his lack of a great reputation in medical circles, especially in Pest. (Numerous doctors took part in the 1848 Revolution and War of Independence and shared a strong Hungarian nationalist sentiment in the 1850s and ’60s.31 ) In addition, occupying the directorial chair of the new large institution to which Schwartzer had also aspired could have decreased his popularity among Schwartzer “students” who indeed made up his staff. His two head physicians: Gyula Niedermann in charge of the male ward and Károly Bolyó in charge of the female ward, as well as other ward doctors like Károly Laufenauer and Jen˝ o Konrád came directly from Schwartzer’s institute. Originally, the asylum was designed for 500 patients but only opened with 300 beds which subsequently increased. In the first years, the average daily number of patients was around 3–400, and by the end of Schnirch’s directorhip, around 600.32 For so many patients, the medical staff consisted of only one directing head physician, two head physicians and four physicians, that is: only seven doctors taking care of the increasing number of patients during the entire observed period (the doctoral staff was increased only in 1918). The administrative staff consisted of five persons, and there were initially 42 nurses, though their number grew during the years. There is little information on how Schnirch ran the asylum. What is certain is that in both Nagyszeben and at Lipótmez˝ o, Schnirch strongly advocated the intellectual occupation of the patients. Teachers were hired by the asylums to instruct the patients in elementary subjects (including geography, history and the natural sciences), reading and writing to illiterate patients, and even a singing master and a physical instructor were hired.33 The second director after the death of Schnirch in 1884 was Gyula Niedermann (1839–1910),34 who earned his reputation for modernising the asylum and for being an exceptionally charismatic alienist. Niedermann (born in Esztergom in 1839) completed his medical studies in 1862, then worked at the Schwartzer asylum for seven years. He taught forensic medicine at the Faculty of Law in Budapest from 1865. Niedermann became head physician in charge of the male ward at Lipótmezõ from 1869. He made long European round-trips with the Public Health Councillor at the Ministry of Interior, Kornél Chyzer, visiting different

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institutions on state money in 1890 and 1896.35 After he left Lipótmez˝ o, Niedermann founded a private mental sanatorium.36 Niedermann emerges from most accounts as a highly prestigious, charismatic figure with great authority in the eyes of his doctors and patients as well. In Oláh’s abbey metaphor, Niedermann is shown as “the provost who is an invisible authority, an abstract concept.”37 He wholly embodied the Schwartzerian type of charismatic alienist: the alienist as the paterfamilias with great authority who manipulates the patients with his psychic power and looks at them as children entrusted to his care in this large family. According to Oláh, he was the just, caring but strict father to the patients, and a “despot” (but “a beloved despot” nonetheless) in the eyes of his employees, who called him “Der Pascha von Leopoldfels.” Oláh was enchanted by Niedermann’s personality and exclaimed that “not before or after him have I ever met a man who had a greater influence on me” (4–5). Oláh mentions Niedermann’s zeal for general doctoring. Niedermann seems to have provided medical care for the entire neighbourhood of the asylum: he was “not idle to pay a visit” even to the poorest sick servant in surrounding villages. It provided Niedermann “with new opportunities to mesmerise souls, while legends of his miraculous cures were circulating” in the region. We can perhaps peek into the nature of these miracles if we consider Oláh’s anecdote he was told by a friend. One day an old baroness was taken to the asylum because her carriage turned over in the vicinity of the institution. While Niedermann diagnosed a broken ankle-bone upon investigation, one of his professor colleagues disagreed with him claiming that the lady suffered no injury whatsoever. Niedermann’s “prestige could not suffer” such an opposition, so he stuck to his own conviction that the bone was broken and had it set in plaster-bandage. The next day, however, Niedermann took off the plaster and congratulated the old lady for the miracle: the bone was healed and sound again. The baroness then, according to the anecdote, had a stone saint erected to commemorate the miracle near the institute (4). Niedermann allegedly feared that escapes would occur at the asylum. As Oláh explained, at that time, preventing escapes was an affair of honour in a well-run lunatic asylum and its good reputation was easily damaged by an escape. It was difficult to escape, as high walls prevented patients from fleeing, yet they still occurred. On one occasion, Oláh remembers, Niedermann was personally leading a group of nurses and other staff who were searching for the fleeing patient with torches and lamps late at night.

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On another occasion, a young imbecile pickpocket escaped from one of the closed gardens but was soon recaptured. The case was inexplicable, since the walls were unclimbable, there was a guard on duty at the gate, and there was no tree too close to the wall. Niedermann interrogated the patient, eager to learn how he managed to escape. “Well, I climbed on a tree, and was swinging myself on a pliable thin branch until I flew on the top of the wall, then climbed down cautiously on the other side.” Niedermann looked at the wall, at the tree, then the wall again; tried to measure the distance with his eyes and shook his head disbelievingly. Then Niedermann asked the patient if he could demonstrate it to him. The patient obediently climbed up the tree again, swung himself high up, flew onto the top of the wall and disappeared—this time irrevocably, forever (4). With the lack of effective sedatives, it was a difficult task to regulate patients and avoid attacks and accidents. In his opening speech at the 1900 National Congress of Psychiatrists, Babarczi Schwartzer drew a dramatic portrait of the alienist. In describing the mission and tenacity of the psychiatrist, Babarczi Schwartzer emphasised the mortal dangers asylum doctors had to face day by day in the practice of their vocation. Continuously being among mental patients, alienists put into danger “not only their physical safety and mental soundness, but their life as well.”38 Accounts of how the doctor perished due to the raving fury of the mad, how cloth together with skin was shredding from those who, with the noble intent of saving and caring, approached an epileptic mental patient, how the doctor collapsed under the fist blows of a lunatic who was in the grip of delusions, how the doctor was bleeding away due to the treacherous attacks of a mental patient acting according to his imperative hallucinations, constitute the sad pages of the history of mental institutions.39

Discounting the rhetorical exaggerations, we may still agree that it was certainly not a sinecure to be an asylum doctor. There were attacks against physicians: for instance, the asylum doctor Jakab Salgó was subject to an attempt on his life, “committed, according to a designed plan,” by two patients armed with knives and iron rods. Another doctor, Dezs˝ o Nagy received a heavy blow on one of his ears that made him deaf on that side, just to be attacked again later by another patient on the other ear.40 Niedermann, who relied on Schwartzerian moral treatment and psychic influence rather than physical restraint, was luckier. According to one of

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Oláh’s anecdotal reflections (this time himself an eye-witness), Niedermann enjoyed a strange habit: he liked walking in front of the patients standing in a line (like inspecting the troops in the army); stopped in front of one or the other and surprised the patients with strange and confusing questions. He then eased them with warm words and smile. Once, when Niedermann, smiling, stopped in front of a patient, a doctor suffering from paranoia, the man reached under his own coat and pulled out a sharp axe, saying with a dangerous look in his eyes. “This is how you guard your patients!” The blood froze in the assistant doctors, including Oláh himself, wondering what would happen next. Niedermann did not stop smiling for a second, looked deep in the patient’s eyes, and asked slowly: “Why do you shave yourself, my colleague? A free man wears a beard.”41 The patient was completely taken aback by surprise, while Niedermann gently took the axe away and moved on to the next patient with a new question.42 During his long directorship, Niedermann managed to modernise the institution. To fight tuberculosis, the most dangerous contagious disease threatening the life of inmates in crowded institutions, Niedermann had the original soft-wood floor-boards (an ideal place for bacteria) changed for the more hygienic, easily cleanable and practical hard ones between 1893–1897.43 As a result, the tuberculotic death-rate fell drastically. István Hollós’ 1909 table demonstrating the percentage of tuberculotic death-rate at the asylum from the 1868 opening to 1900 shows that, between 1868 and 1888, tuberculosis was the cause of death in 16–30% of all deaths at the asylum. In the years 1888–1892, it reached an average 25.4%. In subsequent years, the decrease was considerable: 1893: 12.7%, 1894: 14.5%, 1895: 8.9%, 1896: 8.5%, 1897: 6.7% and 1898: 6.0%.44 To this decrease, better food provision also contributed. Niedermann transformed the system of providing food in 1894 by not catering out, but hiring a kitchen staff for the asylum to cook the meals.45 From 1897, the asylum had its own bakery, and raised pigs,46 poultry and cows which ensured a cheap meat supply and allowed for home processing.47 These changes were advantageous especially for third-class patients who thereafter gained weight.48 They also cultivated vegetables and an orchard.49 Niedermann also improved the nursing staff. The role of nurses having the most contact with patients was crucial in lunatic asylums. Nursing was especially hard work and, ideally, demanded much patience and sympathy from those who undertook the care of the insane. Asylum regulations

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(from as early as Pólya’s time in 1841) and ministerial decrees meticulously detailed the responsibilities and tasks of nurses.50 By the time of Niedermann’s directorship, to be employed as a nurse, one had to be a Hungarian citizen under 35, of blameless character and with clean records, mentally sane and physically able, and capable of reading and writing in Hungarian. Nurses were appointed by the director and could be dismissed only disciplinarily. Immediate dismissal followed the verbal or physical abuse of a patient, theft or embezzlement, amoral behaviour, repeated alcoholism, disobedience, repeated submission of false reports, the violation of the strict prohibitions, serious violation of service rules, and any action against the criminal laws.51 Nurses’ salary and employment conditions were hardly in proportion to the demands of the job, as a result of which nurses often recruited from less reliable, poor and uneducated segments of society, and their turnover was high. In such conditions, it was difficult to demand from nurses high-quality work, reliability and restraint from abusing patients. Although Niedermann realised the benefits of engaging Sisters of the Hospitaller Order to nurse patients and thus employed 24 Sisters from 1893,52 the turnover of nursing staff still remained very high. Table 4.1 demonstrates the lack of continuity in nursing staff at Lipótmez˝ o. As Table 4.1 shows, from the 289 nurses who worked during the year 1895, 183 (63%) were dismissed, out of which 114 “dismissed officially” certainly for some of the reasons listed above. The elaborate list of prohibitions in daily contact with inmates, therefore, not only reflects the good intention of ensuring humane treatment but also provide a variety Table 4.1 The turnover of the nursing Staff at Lipótmez˝ o in the year 1895

Remained at the end of 1894 Newly employed in 1895 Dismissed in 1895 • Upon the nurse’s request • By the director Remained at the end of 1895

Men

Women

Altogether

56 104

49 80

105 184

39 62 59

30 52 47

69 114 106

Source: A Budapest-Lipótmezei magyar királyi Országos Tébolyda jelentése az 1895–1898 évr˝ol (Report of the Budapest Lipótmez˝o Hungarian Royal National Lunatic Asylum, 1895–1898) (Budapest: Különböz˝ o Nyomda, 1896–1899), 17

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of abuses that were regularly committed against patients by the nursing staff.53 Employment conditions were the most important factors that had to be improved in order to retain a better nursing staff by making this career more attractive and deepening the dedication and loyalty of nurses towards the job and the institute. Several decrees from the late 1890s settle the terms of nurses’ pension and employment, which greatly contributed to the formation of a more stable and desirable career at the asylum. “To increase the enthusiasm of nursing staff” employed in public mental asylums and “to ensure the continuity of nurses with appropriate practical training” in these institutions, an 1898 decree ensured pension to nurses. It meant that general nurses were only temporarily employed for five years after which they swore an oath and became permanent staff. After ten subsequent years of continuous service, nurses were eligible for pension if they were disabled. In the calculation of pension, however, only the time of permanent service counted.54 A year later, the five-year probationary period was reduced to one year.55 In 1890, Niedermann founded the Charitable Society for Recovered Mental Patients for the financial support of patients leaving the asylum cured.56 In 1893, he also established a “charity fund” which collected the relatives’ donations as well as the patients’ private fortunes left behind. A 3% handling charge was withdrawn from the patients’ own money for the management of the fund,57 which must have amounted to a considerable sum in such a large institute. From the charity fund, the asylum supported needy patients after their departure, and Christmas presents were bought for the inmates.58 Niedermann retired in 1899, and from 1900 Károly Bolyó (1833– 1906) followed him in the director’s chair. Bolyó was born in Kunszentmiklós in 1832, completed his medical studies in Budapest,59 and was Schwartzer’s assistant doctor at the private asylum between 1857 and 1863, when he published numerous cases and articles on the asylum in the medical weeklies. Granted a travel fellowship, Bolyó visited many European psychiatric institutions between 1863 and 1865, and upon his return published widely on his experience in Orvosi Hetilap (Medical Weekly) and Gyógyászat (Medicine). He was appointed privatdozent of mental health in 1866, and in 1866–68, he led the mental observation ward at Saint Roch Hospital in Pest. When Lipótmez˝ o opened, he moved over with 26 mental patients from Saint Roch Hospital.60 From 1868 he was head doctor in charge of the female ward, then chief doctor and, from

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1899, director of Lipótmez˝ o. Bolyó markedly shaped the profile and life of the asylum since he began his career there. It was Bolyó and his colleague doctor Jakab Salgó who advocated the therapeutic use of baths which were previously used only for daily hygienie.61 (What exactly was meant by daily hygienic needs is dubious. From an 1887 report on the Angyalföld Mental Asylum quoted by Pándy, we learn that patients took a bath for hygienic reasons only once every 10.6 days, although they were supplied with clean dress every day.62 ) In 1896, Bolyó and Salgó had the baths enlarged and introduced modern rational hydrotherapy: applying wet-wrapping and prolonged calmative baths for restless patients.63 With Niedermann’s support, Bolyó and Salgó introduced “bed treatment” in 1896.64 Instead of closing up the restless patients in isolation cells, the doors were left open, and the patients were urged to calm down in their beds.65 Within four years, the bed treatment was used in all four state asylums.66 This treatment led to a decrease in the use of medication. And when it proved to be unsuccessful, the patients received “wet-wrapping”67 (the patient was wrapped into wet sheets) which, due to its highly restraining nature, met the fierce opposition of the patients, who most probably experienced it as coercive and took it as a punishment. The fourth director of Lipótmez˝ o was Jen˝ o Konrád (1854–1919). Born in Veszprém in 1854, Konrád completed his studies in Budapest in 1879, and for three years was a physician at Lipótmez˝ o. He then spent three years studying abroad, with Meynert and Leidersdorf in Vienna, and Magnan in Paris. He also visited English, French and German asylums. Subsequently, he was a practitioner at Lipótmez˝ o and Vienna state mental asylums. From 1886, he was appointed the director of Nagyszeben Mental Asylum, from 1905 to 1910 that of Lipótmez˝ o, and from 1910 the director of the Schwartzer private asylum.68 He advocated “free treatment” which granted the majority of the patients free movement within and around the institute,69 and introduced the system of family care for calm but chronic patients in 1905.70 Finally, the last, fifth director in the period under consideration was Gusztáv Oláh (1857–1944). He earnt his diploma at the Medical Faculty in Vienna and started to work at Lipótmez˝ o in 1881 as a doctor. From 1889, he was appointed director of the Angyalföld Mental Asylum and from 1910, that of Lipótmez˝ o. He was member of the Hungarian Council of Forensic Medicine, president of the Hungarian Society of Mental

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Doctors , and held government and advisory positions concerning mental health care. He retired in 1925. The Use of Coercion and Restraint The use of coercion and restraint in asylum life is a complex question. The history of European psychiatry testifies to a return to the era of the custodial function in mental institutes by the end of the nineteenth century after the great hopes of earlier asylum reformers evaporated. Due to the incredible flood of patients, the inadequate number and training of the nursing staff, and the high rate of dangerous or agitated patients within the patient population, most large asylums could not live up to their therapeutic intentions, and mostly functioned as custodial institutes.71 In such circumstances, it was virtually impossible to always be patient and dedicate the sufficient time and offer the best treatment to individual patients. It was especially difficult to deal with noisy and restless patients living together with calmer inmates in an era when modern effective medication was not yet available. The therapeutic aim therefore clashed with the custodial reality of institutions. Ödön Blum (1862–1936), ministerial councillor in health care issues, complained in 1899 that Hungarian legal regulation of mental health care and the running of asylums in particular reflected police and security concerns72 ; even the structure of older asylum buildings served the purpose of isolation, the hindrance of escapes and the avoidance of physical attacks by raging mental patients.73 Hence, psychiatrists often felt that their hands were tied and were forced to resort to some form of coercion. Yet the use of restraint was deeply problematic for many professionals. Many psychiatrists believed that the use of mechanical restraint tools to curb the freedom of patients, such as isolation in cells, actually caused mental problems and undermined the patients’ socialisation. This was seen as a real problem in most institutions where, as Oláh claimed, the usual large rooms made the adequate grouping of patients impossible according to their mental illness and state of mind and where isolation of the agitated patients was the only means a ward doctor had. The use of isolation in cells together with hypnotic drugs increased desocialisation and actually “produced” “ugly forms” of mental illnesses as the “artifacts” of the asylums, which were nevertheless seen by Oláh in 1902 as luckily rare by those days. Still, if it occurred, they were due to the inadequate structure and management of the institution.74 In the view of the

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public asylum doctor of Angyalföld and then Lipótmez˝ o, László Epstein, “raging” almost always was the product, the natural outcome of the old restraint system. “Since we do not have raging wards, we also do not have raging patients” anymore—he declared in a probably exaggerated statement in 1907.75 After the opening of larger institutions at the last third of the nineteenth century, there were different solutions to deal with cells, for instance; Richard von Krafft-Ebing’s case with Feldhof76 as reconstructed by Hauser demonstrates one of these. Krafft-Ebing was medical director at Feldhof, a large provincial asylum in the outskirts of Graz between 1873 and 1880. Hauser claims that his overall experience at Feldhof was frustrating due to the high mortality and low improvement rate. Although he was an advocate of the non-restraint principle since his time at Illenau in the 1860s (this principle was widely accepted and followed by German speaking psychiatrists in the 1860s and 1870s), he was the one who started to create additional isolation cells because the original four proved to be insufficient. By 1882, two wards containing 34 cells were added, increased to 74 cells by 1888.77 Hungarian alienists seem to have followed a different path. The Schwartzer students Niedermann, Bolyó, Konrád and Laufenauer, but also others like Salgó, all had their first experience with treatment at the Schwartzer private asylum where a non-restraint system prevailed, as discussed in Chapter 3. Rather than building new dark isolation cells in the institutions where they worked, in the end, they got rid of the old ones. It is true that Lipótmez˝ o was built with such cells and was equipped with restraint tools, with the so-called raging table or raging bench. However, these tools, made of iron clamps and strong leather bands to inhibit the movement of the patient, were allegedly never used. At the opening of the asylum, Bolyó immediately discarded them.78 The use of the strait-jacket was in practice, but exclusively upon the order of the doctors, and only for short periods of time. In 1884 when he took over the directorship of the institution, Niedermann terminated their use. After he had returned in 1896 from his study trip abroad during which he visited many foreign institutions, Niedermann introduced “bed treatment” to calm agitated patients, but only to be used for as short period of time as necessary. According to accounts, the introduction of bed treatment and hydrotherapy from 1896 allowed the “free treatment” of patients: patients from closed wards were allowed out to the institute’s parks and, by progressive stages, to the asylum neighbourhood and the

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town.79 In the same year, the darks cells were transformed into normal rooms.80 Free treatment first used at Lipótmez˝ o was subsequently introduced in all public asylums. The 1900 Interior Ministry report confirms this and adds that the relative freedom enjoyed by many patients at state asylums did not prompt them to escape or exhibit aggressive behaviour. On the contrary, the number of escapes and aggressive acts was lower compared to strictly closed institutions. In 1899, there was no serious attack or suicide committed in the Lipótmez˝ o asylum, and only three men and one woman escaped. As the report states, the doctors believed that the price of three or four escapes was not too high for the general freer atmosphere. The report also states that a new operation regulation was in the making which would recommend the introduction of complete “no restraint” principle in all state asylums.81 In spite of this seemingly successful story, the situation seems to have been more complex. First of all, even in professionals’ accounts, the regular insistence on “new” introductions of the no-restraint system suggests that it had to be introduced again and again, that is, even if the principle was widely accepted, practice may have varied and hence it had to be reinforced from time to time. In spite of rhetoric, practice may have kept restraint alive in institutions, as Epstein alluded to the “secret use” of older forms ofphysical restraint in contemporary institutions even where no-restrain system was proclaimed.82 Second, even the notion of non-restraint can be interpreted differently, and if taken in its widest sense, even bed treatment may count as a form of coercion, especially if overused. Epstein enumerated modern substitutes for older forms of restraint that he witnessed: “lidded bath” used in Swiss asylums or “safety belts” in Czech institutes, or the “hydropathic wrapping” of the patients which restricted movement.83 In addition, there was the issue of the use of medication, or as already phrased in contemporary accounts: “chemical restraint.” As Verubek G. claimed in 1909, where the use of strait-jacket became forbidden, the use of cells increased, which resulted in increasingly agitated patients in cells who eventually were provided sedatives and hypnotics to that point that the latter became extremely widespread. “Hyoscin,” “chloralhydrate” and other novel “sedative substances incessantly produced by industrial chemistry” were given to patients as “chemical restraint” treatment. Instead of providing calmness, however, hyoscine, for instance, “elicited agitation due to frightening hallucinations and visions, and the patients felt

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compelled to flee from these, thus producing more motoric restlessness, moving-storm.”84 Even though there is no space here to go deeper into the use of medications in asylums, it suffices to say that hypnotics and sedatives were widely used in the second part of the nineteenth century as they often proved to be efficient means to control agitated, problematic patients who disturbed the others and hence contributed to a more peaceful atmosphere in these institutions. Chemical restraint thus partly substituted physical restraint.85 With more criticism of the overuse of chemical substances emerging by the end of the century, some doctors increasingly avoided the use of medication, which in turn elicited attacks from those professionals who found their application useful. Moderation seemed to be the key in their response. In 1902, Károly Lechner claimed that “we should not be afraid of the use of medication, the ill-reputed chemical restraint, if with it we defend the interests of the patient.”86 Lechner recommended the restriction of the use of hypnotics to the necessary minimum, as they could not be avoided, and believed that narcotics and the separation of the patients could work better than the then fashionable baths which were often unsuccessful and also involved the use of a degree of coercion.87 Salgó similarly recommended the use of medications but emphasised the careful professional choice and moderation in application as the key to their successful use.88 At the same time, Epstein believed that the early use of bed treatment and prolonged bath were efficient forms of treatment to prevent or minimise the use of sedatives and hypnotics in asylums.89 The picture drawn in contemporary reports and the directors’ publications, also has to be modified with information gained from the study of surviving asylum files. Even a non-systematic survey on patients’ original case histories reveal essential information on asylum practices and techniques of discipline nowhere else disclosed or discussed in formal publications. The Lipótmez˝ o case files show that moving patients between the different “departments” of the asylum had both therapeutic and disciplinary functions. These departments were distinguished according to the degree of the patients’ illness; during their often long process of convalescence, patients were systematically moved through these departments. The possibility of being returned to a department housing more disordered patients, however, apparently had a deterring effect. Asylum patient files testify that unruly female patients were explicitly threatened with this prospect if their behaviour did not change. A few cases show that the initial resistance of some patients defiantly choosing this latter option was

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soon broken: they turned more considerate of their situation and after some days, they asked for placement in their previous department.90 The question of what constituted restraint or coercion on the patient leads us to the third issue: whether it was possible at all to manage psychiatric institutions without some form of restraint. Károly Bolyó, who is claimed to have discarded the coercive chains etc. at the opening of the asylum, also wrote in 1862 that he found it justified to use the straitjacket or belts to tie the arms and legs of raging patients to the bed, but only during the time of great agitation and only with the intent to calm and never to punish! All other tools of coercion had to be got rid of.91 In 1897, Epstein, then chief doctor of the Angyalföld Mental Asylum, argued in a paper entitled “On the limits of ‘no-restraint’” that: without pretending to be the spoke-person for the strait-jacket or trying to vindicate legitimation for its use in mental health care, I nevertheless openly admit that I rather see the rational use of the strait-jacket, than the continuous use of injection, as I cannot professionally or morally justify committing a systematic poisoning of the patient.92

Epstein also admitted that patient management and treatment was hardly possible without resorting to some sort of restraint sometimes: I do not believe that it was right to avoid the use of strait-jacket if its use was necessary, and to endanger the physical safety and perhaps even the life of the patient just to avoid offending a proclaimed principle. If somewhere, it is in medical practice where … one should not march under the banner of slogans.… each case needs to be judged individually and treated according to the expediency or possibilities.93

Jen˝ o Konrád held similar views, he believed that the temporary use of restraint tools was sometimes unavoidable in the interest of the patient. The professional knowledge and humanism of the doctor had to be the guarantee not to abuse it.94 Forms of restraint thus unavoidably remained present in psychiatric institutions, although they were substituted with novel forms of restraint and some of their use became more careful and restricted. In addition to refrainment from the use of old coercive tools, another lesson most of these directors and head physicians learned at Schwartzer’s private asylum was the importance of the patients’ occupation, something that turned out to be the most beneficial for the patients and efficient way

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to fight unrest and bad behaviour. Under the direction of craftsmannurses, patients could work in well-equipped tailor, carpenter, shoemaker and bookbindery workshops. Some of the patients produced valuable pieces of furniture, items for interior decoration, dresses and shoes. Calm patients did simple office jobs at the asylum. Women mostly did needlework, embroidery, hosiery and made underwear. Gardening and housekeeping were open to anyone, and Lipótmez˝ o had its own workshop to produce kitchen equipment. Epstein believed in 1907 that the introduction of the no-restraint system, together with the regular occupation of patients contributed to the gradual disappearance of not just the raging patients, but also the shabby-looking, dirty patients with dull expression on their face, staring in front of them, motionless most of the day, which constituted a characteristic group of the patient population in previous eras.95 Patients could also give expression to their artistic impulses. The council chamber’s table with six wooden chairs, for example, were carved by the paranoid Imre Schreiber and the alcoholic Imre Horváth who also suffered from dementia praecox in 1880. Patients received a salary for their work which was either paid in cash, or in kind to improve his or her meals, for tobacco, or for amusements and celebrations.96 Amusements were also not lacking in the asylum. Theatrical performances and concerts provided entertainment during the year. The fine location of the asylum, its huge parks and woods made sports and communal amusement possible throughout the year: sledging in the Winter, and tennis, o patients garden parties, excursions in the Summer.97 Many Lipótmez˝ even visited the Millennial Exhibition in Budapest in 1896.98 Such activities certainly helped to keep patients in a better mental and physical state and increased their well-being.

Legal Regulation Versus Reality of Admission, Discharge and Guardianship in Asylums and Psychiatric Hospital Wards In the lack of any scholarly reconstruction of the history of the legal regulation of the above issues and their implementation in practice in the given period, I had to turn to vast collections of acts, laws and regulations to screen for those dealing with mental health issues. What we can gain from them is no clear chronology or easy periodisation of these developments,

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rather, a somewhat chaotic picture of more or less desperate attempts at gradually regulating asylum-related factors, from which nevertheless some clear conclusions can be drawn. In spite of endeavours to regulate the processes of admission, discharge and placement under guardianship, the same resolutions and acts suggest that reality mostly did not live up to the expectations of the lawgivers. Medical and Bureaucratic Criteria and Conditions of Admission As discussed in the third chapter, the admission and functioning conditions of Pólya and Schwartzer’s private asylums (founded in 1841 and 1850, respectively) were already clearly enumerated in foundation documents and reports. There was a keen stress on the institutes’ medical qualities: admission required the expert opinion of doctors and the detailed prehistory of the patient’s familial and medical background. The professed goal of the institutes was curing, thus the foundation documents and official reports expelled the untreatable cases of “idiots” and “imbeciles.”99 Treatment in Schwartzer’s institute combined traditional medical service to the body and moral treatment for the re-education of the soul and personality. With the rise of public state asylums from the 1860s, different aspects of asylum life as well as the bureaucratic and legal conditions of patients’ management became elaborately defined. The 1862 Basic Regulations of the Nagyszeben Royal National Lunatic Asylum defined the aim of the institute as providing “expedient accommodation and medical treatment” for curable mental patients or those dangerous to the public (recruiting its patients from Transylvania and other crown territories).100 Just like the Schwartzer asylum, the institute did not admit “idiots and cretins,” whereas it also ruled out, in principle at least, the admission of epileptic patients.101 The Lipótmez˝ o 1868 Foundation Regulations more clearly differentiated between the double function of the treatment of curable patients and the “custody and care” of incurable and dangerous patients from all over the Kingdom.102 Within fifteen years, however, the great number of patients of the latter group, that is: incurable and dangerous to the public, threatened to completely paralyse the institute in fulfilling the purpose of treatment. Therefore, the Angyalföld Mental Asylum was set up to relieve other institutes from these most hopeless of cases, but it could not provide a lasting solution.103

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As to the medical criteria for admission of patients by the director or one of the assistant doctors, both Nagyszeben and Lipótmez˝ o asylums required a certificate of insanity by a public or private practitioner. If it was possible, a written document was also to be submitted from the doctor who had previously treated the patient containing a recommendation for hospitalisation, a detailed account of the history of the patient’s disease (its cause, onset, process and symptoms), and a prognosis concerning the outcome of the disease.104 The 1876 Public Health Care Act ordered that no-one could be admitted to a lunatic asylum without a certificate on his/her mental illness by a doctor with public office and by the patient’s previous doctor who treated him.105 This, however, practically meant that, in the lack of sufficient number of trained mental pathologists in the country (and especially in the countryside), mental patients were sent to asylums by general doctors whose certificates were to constitute the basis for temporary admission.106 In spite of these requirements, however, in reality many important pieces of medical information were missing at the time of admission throughout the observed period. Already during the first decade after the institutions’ opening, such missing pieces of information concerned the illness’ onset, development, course and most important events as well as the patient’s familial background. Such unsatisfactory admission circumstances were seen as “especially disadvantageous to the institute, to treatment as well as to the judgement of the certain case.”107 Thus, following the National Public Health Council’s recommendation, the Interior Ministry issued in 1874 a detailed questionnaire that was sent to all public asylum directors and was meant to help them collect crucial data concerning the patient’s mental disorder. If the director found it necessary, this questionnaire was sent to the patient’s local authorities who gathered information, filled it out and sent it back to the asylum director.108 Such shortcomings in the medical aspects of admission remained characteristic throughout the period.109 According to the bureaucratic criteria of admission already specified in asylum foundation documents in the 1860s, the patient had to possess a certificate issued by local authorities concerning his/her birthplace and domicile. The admission papers had to include information on the costs of treatment, the circumstances of payment (who pays for the patient, whether it only partially covers the costs, or whether the patient and his/her family was unable to pay) and in which food class the patient was admitted. Lipótmez˝ o also required a declaration by relatives that the

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cost of treatment would be met punctually, one month in advance. A private person’s solvency had to be officially proved, whereas in case of foreign patients, the asylums required a Hungarian sponsor. Relatives and sponsors also had to accept that they were responsible to take the patient out of the institute if the latter required it.110 Patients whose treatment costs were guaranteed were admitted directly by the director, whereas in case of poor patients, preliminary permission by the Interior Ministry was required.111 The 1875 III Act on covering the costs of public patient care even more systematically laid down the principles of admissions.112 In spite of the detailed bureaucratic regulations, however, the reality of admissions was chaotic in this respect as well during the entire observed period. Within a few years after their opening, both Nagyszeben and Lipótmez˝ o public asylums admitted mental patients without the required medical and official documents as well as patients who were not supposed to be treated in these institutions at all. In 1870, the Ministry of Interior warned the municipal authorities that, unlike the practice showed, no patient should be admitted to public lunatic asylums at public expense without preliminary permission by the Interior Ministry.113 The following year another decree forbade the admission of poor patients without ministerial permission and also criticised the practice of admitting—at public expense—“idiots,” “cretins” and epileptics who were neither curable nor dangerous. As the decree commented, these patients were taken to lunatic asylums because “family and community care meant (undesired) inconvenience and costs.”114 This suggests that the advent of asylums was seen by families and local communities as a possibility to escape from the financial and other burdens the care of an insane person meant for them. Another 1871 decree by the Interior Ministry states that required certificates of poverty (of both patients and their relatives) are often issued by the local authorities without adequate investigation of the concerned family’s real financial situation. The decree qualifies it as “not properly applied charity” so that families are spared paying for the arising costs, while this inadequate procedure “imposes unjustified (financial) burden on the Treasury.” The Interior Ministry thus required from all municipal authorities more rigorous examination in this respect, since “the state covers these costs only in case failing all else.” The Ministry reminded communities that it was in their interest as well, since in the case there was no solvent relatives, the communities had to cover the costs.115

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Many patients were taken to lunatic asylums by relatives or the communities without the required documents and permission. The directors did not have many choices: they either refused these patients’ admission according to the rules and the patients were transported back home “at a great distance, often in severe weather,” or, to avoid exposing the patients to such calamities, the directors temporarily admitted them without the necessary information whether the certain institute was an adequate place for their treatment.116 The situation did not get better as the following decades unfolded and overcrowding increased. In the 1880s and ’90s, both public mental asylums and hospital psychiatric wards demonstrate shortcomings in both medical and administrative aspects of admission. Overcrowded, psychiatric hospital wards also transferred their incurable and not dangerous patients to mental asylums rather than back to their domicile to be treated in community care—as the law required. Several ministerial decrees refer to numerous instances when patients were taken to the asylums without the necessary medical certificates. Relatives were sometimes directly advised by local authorities to take their mentally disordered kin to institutions without seeking preliminary permission, which often resulted with the patient’s refusal who were thus “exposed to excitation as well as being dragged back and forth.” The situation was so bad because “state mental asylums are so overcrowded at present that mental patients can only be placed there with the greatest difficulties.”117 In the 1880s, hospital psychiatric wards show similar shortcomings in implementing the law. As a result, in 1888 the director of Saint Roch Hospital was ordered by the Minister of Interior to refuse poor mental patients from the countryside who had no preliminary permission from the Ministry, unless the hospital doctor found the patient “irrefusable” due to his mental condition or if his transportation was impossible because of it.While Saint Roch and Saint John’s Hospitals in Budapest were primarily to provide medical care for patients with domicile in the capital, their psychiatric wards admitted numerous patients from the countryside who were taken to the capital by their relatives which further aggravated overcrowding in these institutions. It was morally difficult for doctors to refuse patients, while the admitted incurable and dangerous patients who were from time to time taken to the ward meant a great burden for the hospitals whose directors sometimes sought permission from the Ministry of Interior to banish these patients from the institution.119

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Since hospital psychiatric wards were not designed for the long-term care for dangerous and incurable mental patients, they sought to rid themselves of these patients by transferring them to lunatic asylums in “great numbers.” As a result, the Angyalföld Mental Asylum became overcrowded by 1889. An 1889 ministerial decree, for instance, “appreciated” the doctors’ endeavours at Saint John’s Hospital to take care of their patients’ future and place most incurable mental patients in lunatic asylums where they could “enjoy the advantages of a well-equipped national institute.” However, it warned the hospital that care for “easily restrainable patients” was the responsibility of the community.120 It is important to emphasise that these problems arose most acutely in the case of poor patients who were unable to pay for care and thus meant a burden for the local community as well as the state. Not dangerous incurable patient whose family was able to pay the costs could only be admitted to mental institutions if there were available beds.121 According to the law, the care for poor incurable and not dangerous mental patients had to be organised by the community and not in public institutions ran by the state.122 The Ministry of Interior, however, was aware that many communities in the country were poor and did not have the resources to achieve this task, where “the care for even one or two patients is a great burden.” In these cases, the state was willing to finally cover patient costs from public funds.123 The conditions in Budapest were different. Here local funds were more abundant than in poor countryside regions, thus the Ministry “all the more expected from the capital” to ensure care for such patients “worthily of its developed public institutions.” However, even in Budapest the practice showed that numerous incurable and not dangerous mental patients ended up in Angyalföld Mental Asylum or the psychiatric ward of the Buda Hospital of the Hospitaller Order, which the Interior Ministry highly criticised. To enforce the law, the decree repeatedly ordered the managements of Angyalföld Mental Asylum and the Buda Hospital of the Hospitaller Order not to admit Budapest mental patients who should be in community care and commanded the director of Saint Johns’ Hospital to be “most rigorous and scrupulous” in qualifying incurable patients (especially from the capital) for asylum care. To have a look over these practices, the Ministry required three monthly reports on the number of incurables sent to community care from hospital psychiatric wards in the capital.124

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There were problems with the mode of taking mental patients into the asylums and hospital psychiatric wards as well: they were often escorted by the gendarmerie. In 1885, the Ministry of Interior had to order local authorities to provide mental patients with experienced attendants who had expertise in dealing with the mentally disordered, in an ideal case a trained nurse. Escorting discharged mental patients home or to other institutions from public asylum was better organised and usually completed by nurses employed by the asylums.125 That the situation was not satisfactorily solved is suggested by a further decree in 1903 which, alluding to abuses in this respect, prohibited patients ever being taken to mental institutions by the gendarmerie. If a policeman was used for such a task, he had to wear civil garment without police equipment.126 The Double System of Admission and Guardianship According to the 1876 Act, a patients’ admission to an asylum had two stages. First, the patient was only temporarily admitted—in the ideal case—with the necessary medical certificate stating insanity. The 1876 Act established an “external control system” in private asylums and hospital mental wards, while in public asylums, it introduced the “observationsystem.” In case of private asylums and hospital mental wards, external control meant that the patient could only be finally admitted after the court of competent jurisdiction determined his or her mental illness. Therefore, the court had to be immediately notified of a temporary admission. In public asylums, the patient was finally admitted on the personal responsibility of the director after the patient’s mental illness was confirmed by the director during an observation period. After such determination, the director was required to send his medical findings to the patient’s court of competent jurisdiction without delay. With this double system existing between private asylum and hospital mental wards on the one hand and public asylums on the other, the 1876 Act laid far more power into the hands of the public asylum director who, with a lack of external medical control, could decide about the insanity of the patients.127 According to Babarczi Schwartzer, the unfortunate fact that external control was not introduced in to public asylums was due to financial constraints and “the whole thing depended on exactly 7,000 forints.” At the same time, Babarczi Schwartzer insisted that, in spite of this, there was not a single case of abuse (by asylum directors) during the previous 50 years.128

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In principle, patients’ permanent admission (with a confirmation of his/her insanity) and the involvement of the courts and local authorities were significant in the process of initiating guardianship for mental patients. The conditions of placing a mental patient under guardianship, however, were not clearly defined. There are references to this in the public asylum basic rules and some decrees, but no laws or decrees systematically and satisfactorily regulated the question. The 1862 Nagyszeben Basic Regulations stated that all mentally ill persons must have a legal guardian; until the guardian was officially appointed, a person had to represent the insane’s interest in his relationship to the asylum.129 But the Basic Regulations did not specify what procedures were necessary to appoint guardians. The Lipótmez˝ o Foundation Regulations did not clarify the procedure of placing patients under guardianship either. It required that the director notify local authorities concerning an admission, and some paragraphs mention guardians’ role, especially at the discussion of discharge procedures.130 The 1876 Act also did not discuss the issue of guardianship. The question was finally treated—though not adequately settled—in the 1877 XX Act. The 28th paragraph required that mental patients, the deaf and dumb (and those who were unable to express themselves with signs), as well as imbeciles be placed under guardianship. The 96th paragraph required from guardians to include an account of the health conditions of the person under guardianship in the annual report submitted to the public court of guardians (gyámhatóság). Furthermore, the 258th paragraph stated that, after consultation with relatives, the board of guardians (árvaszék) designated a temporary guardian until a permanent was appointed by the court.131 A few modifications were made on this law in 1885.132 In reality, however, neither hospitals and private institutions, nor public asylums followed the letter of the law in all cases. A year after the 1876 Act, a general decree by the Ministry of Interior already complained that the courts were usually not notified by private asylums and hospital mental wards about the admission of patients,133 which means that, in these cases, neither the patients’ mental state was observed by an external committee, nor were the patients under guardianship. An 1881 decree ordered the director of Lipótmez˝ o State Asylum to report to the court of competent jurisdiction concerning the observation of prisoners under its remand at least every two months. The reason for the ruling was the case of such a person who had already spent an entire

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year in the institution for the purpose of mental observation, but the director did not produce a single account on his mental state. Although the ministry accepted that “no time-limit can be rendered to the judgement on mental state,” it ruled that reports had to be regularly written, to give account of what was detected and what hindered a final judgement from time to time.134 The prevailing practice of initiating guardianship caused problems and raised criticism from the psychiatric profession. By the turn of the century, the issue was seen as so urgent that the second lecture by Jen˝ o Konrád (director of Nagyszeben public mental asylum) at the 1900 First National Alienist Congress focused precisely on this issue and elicited many responses from the professional audience.135 The main problem concerned the “uncontrolled power” of the directors of public mental institutions in placing mental patients under guardianship. Babarczi Schwartzer’s 1897 Közigazgatási elmekórtan (Administrative mental pathology) also discussed problems with this “uncontrolled power” of directors.136 He noted that the state focused the responsibility of control in one person: the director. According to Babarczi Schwartzer, the only “guarantee” for the proper implementation of legal resolutions was the official oath of the director, an important condition of his appointment. Therefore, the director’s official oath was seen as a pledge of moral credit that the state found as sufficient, whereas psychiatrists (some of the directors themselves, like Konrád) criticised it. In Babarczi Schwartzer’s words, this concentration of power in one hand “weighs with a heavy responsibility on the director and exposes his personality to possible accusations.” Since decisions about guardianship “depend on the person of the director alone, that is, on his individual merits,” no such decision could constitute an “absolute and satisfactory” solution in all cases.137 In Konrád’s views, such a concentration of power was destructive to the director’s reputation as well.138 He referred to numerous sensational news reports in dailies claiming that sane people were imprisoned in mental asylums. The fact that such news appeared was not in itself a problem for Konrád, since “in the great open space of public life, it is also a form of control.” The problem was that “perhaps a majority of the people believe it, which is disadvantageous to the mental institutions as well as psychiatrists.” Therefore, it was in the interest of psychiatrists themselves to propose regulations that “defends individual freedom.”139 This heavy criticism of the power of directors raised by a director himself

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and shared by many of his colleagues demonstrates a great deal of selfreflection and the safeguarding of both the patients’ as well as professional interests by members of the psychiatric profession. The practical implementation of external control and appointing guardianship in hospital mental wards also revealed numerous shortcomings. At the Congress, Jakab Fischer, chief doctor of Pozsony Hospital, agreed that legal security necessitated external control in all institutions. The practical execution of the law, however, was not always possible. According to practise at his hospital, for instance, the director notified the court about each case of patient admission; then Fischer himself was delegated by the court as an expert. After Fischer gave a certificate of insanity, the court placed the patient under guardianship.140 Although Fischer did not specify the problems with this practice, it is obvious that, in these cases, it was not an external committee comprising two psychiatrists that decided about the mental state of patients, but one of the doctors from the hospital ward itself. In his contribution to the discussion, the hospital chief doctor Károly Pándy from Gyula related his experience with external patientexaminations at hospital wards. Pándy stated that, according to the order of the 1876 Act and an 1898 decree,141 the Gyula Public Hospital notified the court in each case of patient admission. In the year 1899, however, the court sent out a committee only two times, and responded in more than 100 cases that the external control only applied to private institutions and not to public hospitals, and thus refrained from further action. Pándy concluded that the courts acted against the wording of the law (which required such external control in hospital mental wards as well). As a result, if hospital directorship failed to directly request the placement of a patient under guardianship, the courts did not deal with the detention of patients in these institutions.142 Pándy also criticised that, while courts had to initiate guardianship at the request of public hospital directors, no decree or law obliged these directors to make such a request.143 Pándy claimed that, due to these shortcomings, in several cases patients were kept at mental wards for years without being placed under guardianship (and often even without a medical certificate).144 At this point, Laufenauer intervened and denied that it had ever happened.145 Other psychiatrists at hospital mental wards from all over the country, however, confirmed the gloomy picture painted by Pándy. Zsigmond Telegdi, hospital head doctor in Kaposvár, stated that no

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court committee visited his ward to observe patients’ mental state.Henrik Szigeti, forensic psychiatrist from Temesvár confirmed that, according to his knowledge, court control was usually not practised in hospital wards. He found its reason in that there was no allowance for travel and other costs of such delegations.Kálmán Glósz, hospital chief doctor in Eger, stated that the court always accepted his case histories based on which it could initiate guardianship (instead of sending an external committee). Glósz highly disagreed with this practice.148 As these comments reveal, neither the legal regulation of these issues, nor their implementation by asylums, hospital psychiatric wards and courts were proper and satisfactory. To adequately settle the question of admission, acquittal and guardianship, Konrád offered a detailed proposal that sought to unify regulation of these questions in all forms of mental institutions in the country. He stated that the external control regarding both the admission and the acquittal of patients must be extended to all mental institutions. According to his outlined principles: 1. In all cases of patients permanently admitted, the director of the institution had to notify the court of competent jurisdiction which, in turn, had to send out a committee for the observation of the patient’s mental state. In case the patient was found insane, his/her placement under guardianship had to be initiated by the court. 2. The director also had to notify the court in case a patient was regarded as cured. If recovery was confirmed by the committee sent out by the court, the court had to initiate the termination of guardianship. 3. If, contrary to the director’s opinion, the relatives or the guardian of the patient regarded the patient cured or wished to initiate his acquittal as cured, they had the right to request the observation of the patient by a court committee at their own expense. 4. To defend the interest of patients who had no relatives and whose officially delegated guardian might not have adequately guarded the patients’ interests (and to avoid their unlawful detention), Konrád proposed that an expert committee set up by the Ministry of Interior should check the patient population of mental institutions from time to time. In case this committee found patients whom it regarded as cured (even if this view conflicted with the director’s opinion), it was required to notify the court.

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5. If relatives wished to take out cured patients from the institution before a court committee observed the case, the director was allowed to discharge the cured patient in a simple administrative way. He had to notify the competent court about the acquittal. Administrative discharge in itself did not mean that the patient was removed from under guardianship. 6. The director immediately had to discharge patients found as cured or not insane by the court committee. 7. The court committee observing mental patients should comprise a judge, a court clerk and two expert psychiatrists (preferably one of them the head doctor of the institution, the other the doctor who actually treated the patient and wrote his case history).149 This would have unified the system by requiring external medical control for all types of institutions, including public mental asylums as well, and the discharge process would also have necessitated external medical decision. It would have greatly curtailed asylum directors’ power and given more power to patients’ relatives and the guardian. Concerning Konrád’s last point, while it was certainly advantageous to have the doctor who previously treated the patient at the institution present at the observation by the committee (since this doctor was the most familiar with the course of disease), if the psychiatric experts in the committee were the institutions’ doctors, it again did not satisfy the requirement of externality. The reason for this practical choice of the institute’s doctor probably was the lack of trained psychiatrists in the country. The two doctors in the juridical committee had to be experienced psychiatrists, otherwise their observation was a mere formality. The practical difficulty with the execution of external control in all institutions in the countryside was clearly the lack of such experts. There were simply no available psychiatrists who were not employed in mental asylums.150 To guarantee the supply of adequate number of experts, Pándy saw the solution in making psychiatry a compulsory study and exam at the Medical Faculty.151 All contributors to the debate supported the extension of external control to all mental institutions. But Laufenauer warned against the early placement of patients under guardianship. It had a high cost for poor patients to seek relief from guardianship once cured, Laufenauer argued.152 Moravcsik agreed with Laufenauer that early guardianship was not in the interest of the patient, nor was it demanded by the law.

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He stated that no ministerial decree contained a “precise resolution” concerning the placement of patients under guardianship, and courts also hesitated to place patients under “temporary guardianship.”153 Salgó went even further and suggested that the external committee should observe the patient on several occasion before making a decision, and permanent guardianship should only be initiated once the patient’s incurability was stated.Babarczi Schwartzer proposed the idea of “temporary guardianship.”155 From the psychiatrists’ viewpoint, the issue of guardianship was problematic and unresolved in theory as well as practice. Psychiatrists complained about the formal power of public asylum directors that they saw as damaging to the profession’s reputation as well as to individual freedom. I close this section with a case that demonstrates another aspect of the informal power of the psychiatrist as well as points out another condition that was seen as essential in deciding about insanity and guardianship. Konrád began his presentation on guardianship at the 1900 National Alienist Congress by relating the case of one of his patients. A wealthy Hungarian upper-class lady escaped home from a foreign mental asylum. Her husband, who lived separately from her, immediately brought an action against her in court in order to place her under a guardianship. At the court, he presented a lengthy case history and opinion written by the director of the institute stating that the woman was insane as well as weak-minded who was incapable of managing her properties alone. The lady’s lawyer contacted Konrád to seek another expert opinion. After several weeks of observation, Konrád came to the conclusion that the lady indeed had suffered from mental illness, but at the time of the observation, she was already cured and gave proof of great erudition and intelligence. The only problem was that the lady refused “admission” of her former insanity. She claimed that she had not been mentally confused before, only very upset because she had quarrels over property with her husband. Her husband had her closed up in a mental asylum in order to gain control over the children and the management of her properties.156 Konrád was aware that the court would seek further psychiatric opinions due to the conflicting expert opinions by the foreign director and himself. Therefore, he told the lady that she was already cured of her disease, but this had a small flaw, “she cannot, or is not willing to admit that she had been insane.” “I am not demanding this admission from you, you may think whatever you want, but I seriously advise you to

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admit that you were insane when doctors observe you, otherwise you will raise doubts in them and, in the lack of time for longer observation, they may deny you the certificate of sanity”—Konrád warned her. “Therefore, I do not hesitate to admit that I trained her how to produce this criteria of recovery in front of those who may overestimate its importance.”157 Most participants in the debate agreed with Konrád. As we have seen, the legal regulation of admission, discharge and guardianship was not adequately settled, and there were considerable discrepancies between legal requirements and the actual practice in different institutions. It seems that families and local communities tried to rid themselves of the burden of taking care of incurable and not dangerous relatives for financial and other reasons and the mental asylums seemed to provide an easy solution for these problems. In the 1880s and ’90s, both public mental asylums and hospital psychiatric wards demonstrate shortcomings in both medical and administrative aspects of admission. Even if the law required medical certificate from two doctors concerning the mental state of the patients to be admitted to public institutions, these were mostly provided by general medical professionals rather than those trained in mental pathology. In spite of the detailed bureaucratic regulations, medical and other official documents and permissions were regularly missing at thus the reality of admissions was rather chaotic. The double system of confirming the mental state of patients and the initiation of guardianship procedures after admission that existed between public asylums (where there was no external control of such medical judgement and procedures) on the one hand and private asylums and hospital wards (where such external control existed, at least in principle) on the other hand placed an unprecedented power into the hands of asylum directors which was heavily criticised by professionals, including some of the directors themselves. The assignment of guardians for mental patients was a complex procedure which was not adequately settled by the law, not to mention the reality of relevant institutional practices.

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Notes 1. The article was published before the three municipal territories of Pest, Buda and Óbuda were unified as Budapest in 1873. 2. Vasárnapi Újság (Sunday News),“Látogatás a lipótmezei tébolydában” (Visit to the Lipótmez˝o Lunatic Asylum), June 13, 1869, 328. 3. Several designations were used for the asylum in the observed period. Instead of the original Lipótmez˝ o Royal National Lunatic Asylum, it was often called as Lipótmez˝ o State or Public Lunatic Asylum, or simply as Lipótmez˝ o lunatic asylum in different official documents, psychiatric writings and publications. In the last decades of the nineteenth century, it often appears as Lipótmez˝ o mental asylum or institution. It was officially renamed as Hungarian Royal State Mental Institute in 1897; see 1897 No. 93,726 decree issued by the Ministry of Interior, in Kornél Chyzer, ed. Az egészségügyre vontakozó törvények és rendeletek gy˝ ujteménye. 1895–1900 (Collection of Laws and Decrees Concerning Health Care. 1895–1900) (Budapest: Dobrowsky és Franke, 1900), 364. For the sake of simplicity, in the rest of the book I generally use the simple “Lipótmez˝ o” designation—as the institution commonly existed in the public mind and was referred to in numerous articles. 4. For the argument that Lipótmez˝ o became a “concept” in the public mind, see among others: László Epstein, “A lipótmezei állami elmegyógyintézet szerepe a magyar elmegyógyászat fejl˝ odésében” (The Role of Lipótmez˝ o State Mental Institution in the Development of Hungarian Psychiatry). Gyógyászat (Medicine) 27 (1922): 400. 5. Gusztáv Oláh (1857–1944) director of the Lipótmez˝ o asylum from 1910. 6. Pannonhalma was the largest early-Medieval Benedictine monastery built in 996 that became a significant cultural and institutional centre in subsequent centuries. 7. Gusztáv Oláh, “Emlékezzünk régiekr˝ ol” (Remembering Psychiatrists in the Past) (Unpublished manuscript of a Lecture Given in 1922): 3. 8. Oláh (1922), 5.

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9. The Compromise redefined the constitutional, political and economic relationship between the two parts of the empire until its dissolution at the end of WWI. 10. Oláh (1922), 1–2. 11. For the latter argument, see, for instance, László Epstein, “Magyarország elmebetegügye” (Mental Health Care in Hungary), Gyógyászat (Medicine) 38 (1897a): 580–583, 598, and Ern˝ o Moravcsik, “A psychiatria fejl˝ odése hazánkban az utolsó 50 év alatt” (The Development of Psychiatry in Our Country During the Last 50 Years), Orvosi Hetilap (Medical Weekly) 1 (1906a): 38–42. 12. See the Archives of the Lipótmez˝ o National Mental and Nervous Institute, Budapest. The archives which contains rich documentation on the building process, plans, etc., however, does not use archival catalogisation for the nineteenth-century material, therefore no catalogue numbers can be provided. 13. Erna Lesky, The Vienna Medical School of the Nineteenth Century, trans. L. Williams and I.S. Levij (Baltimore, London: Johns Hopkins University Press, 1976), 151. 14. I discuss these questions in detail later in the chapter. 15. For this statement, see, among others, Rudolf Fabinyi, “A Lipótmez˝ o 50 esztend˝ os” (Lipótmez˝ o Is 50 Years Old). Orvosi Hetilap (Medical Weekly) 24 (1922): 249; Kálmán Pándy, Gondoskodás az elmebetegekr˝ol más államokban és nálunk (The Care for Mental Patients Abroad and in Our Country) (Gyula: Corvina, 1905), 375. 16. Lesky (1976), 151. 17. For architecture and psychiatric spaces, see James E. Moran, Leslie Topp, and Jonathan Andrews, eds., Madness, Architecture and the Built Environment: Psychiatric Spaces in Historical Context (Abingdon, UK: Routledge, 2007). 18. See Vasárnapi Újság (1869): 325, 328. The author of the article emphasises the “nice quietude, exemplary order and cleanliness” that awaits the visitor in all sections of the asylum, in the rooms of the wealthy as well as the poor. 19. See János Fekete, “Intézetünk megalapítása, és m˝ uködése 1900ig” (The Foundation of Our Institute and Its History Until 1900), in Az Országos Ideg- és Elmegyógyintézet 100 éve (Hundred Year Anniversary of the National Institute for Nervous and

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Mental Diseases), ed. Zoltán Szabó, Zoltán Böszörményi and Mária Kuntner (Budapest: Országos Ideg- és Elmegyógyintézet, 1968), 72. In 1867, Gusztáv Zombory mentions “two churches for the meeker and improving Catholic and Protestant patients.” See Gusztáv Zombory, “A lipótmezei országos tébolyda Budán” (The Lipótmez˝ o National Lunatic Asylum in Buda), Hazánk s a Külföld (Our Nation and Foreign Countries) 43 (1867), 680, as well as Vasárnapi Újság (1869): 325, 328. 20. According to the Lipótmez˝ o foundation regulations, patients could practice religion and attend masses only with the consent of the director and the head doctor, and only to a degree the “patient’s mental condition and the measure of the therapeutic aim” allowed. See Alapszerkezet a budai országos tébolyda számára (Foundation Regulations of the Buda National Lunatic Asylum) (Budapest, 1868?), 10. 21. These were turned into small separate baths only in the 1930s. 22. For the therapeutic use of baths, see below. 23. In the 1890s water pipes were laid in, and thereafter patients drank the cleaned water of the Danube. Fekete (1968), 72–73. 24. Zombory (1867), 680. 25. See Vasárnapi Újság (1869): 325, 328. The author’s tone immediately changes as he describes the raging cells, see discussed below. 26. See Vasárnapi Újság (1869): 325, 328; Zombory (1867), 680. 27. Kálmán Pándy, Emlékkönyv a nagyszebeni m.k. állami elmegyógyintézet ötven éves fennállásának évfordulójára (‘Memorial Book’ for the 50th Anniversary of the Nagyszeben Hungarian Royal State Mental Institution) (Nagyszeben: Haiser György Nyomda, 1914), 90–91. 28. See Pándy (1914), 90–91 and István Zsakó, “A nagyszebeni elmegyógyintézet százegy éves múltjának néhány kevéssé ismert adata. Adattár” (A Few Less Known Data on the 101-Year History of the Nagyszeben Mental Institute. Collection of Data). Az Országos Orvostörténeti Könyvtár Közleményei (Publications of the National Library for the History of Medicine) 36 (1965a): 215–219. 29. See Pándy (1914), 90–91. 30. Oláh (1922), 2.

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31. Gy˝ oz˝ o Zétényi, A magyar szabadságharc honvédorvosai (Military Doctors in the Hungarian War of Independence) (Budapest: Egyetemi Nyomda, 1948). 32. See discussed below. 33. See Pándy (1914), 92–94. 34. According to Pándy, Schnirch retired in 1876 and Bolyó substituted him. This is not confirmed by any other source I consulted. Pándy (1905), 377. 35. See their resulting publication: Gyula Niedermann, and Kornél Chyzer, Elmebetegügy, iszákosok menedékhelyei, és védekezés a tüd˝ovész ellen (Mental Health Care, Asylums for Alcoholics, and the Fight Against Tuberculosis) (Budapest: Magyar Királyi Belügyminisztérium, 1897). 36. See, among numerous sources, Epstein (1922), 400. 37. Oláh (1922), 5. 38. Ottó Babarczi Schwartzer, “Az állami elmegyógyintézeti orvosok helyzetér˝ ol” (On the Situation of Doctors at Public Mental Institutions), in Az 1900. évi október 28–29-én Budapesten tartott Els˝o Országos Elmeorvosi Értekezlet munkálatai (Proceedings of the First National Alienist Congress, Held in Budapest, on 28–29 October 1900), ed.László Epstein (Budapest: Pallas, 1901), 35. 39. Babarczi Schwartzer (1901), 36. 40. See Fabinyi (1922), 249. 41. Wearing a beard (modelled on the widely popular liberal politician Lajos Kossuth’s) after the 1848/49 revolution and war of independence became a symbol of political resistance. 42. Oláh (1922), 4–5. 43. This shows a sophisticated practical use of contemporary knowledge in the field of bacteriology. The same exchange of soft-wood floor-boards for hard ones was only implemented at Nagyszeben lunatic asylum in 1902, see Pándy (1914), 44. 44. István Hollós, “A lipótmezei állami elmegyógyintézet 40 évi betegforgalma 1868–1908” (Patient Admissions and Discharges at the Lipótmez˝ o State Mental Institution During the 40 Years between 1868–1908) Orvosi Hetilap (Medical Weekly) 53, no. 18 (May 1909a), 82. 45. Pándy (1905), 382; Ministry of Interior, Magyarország elmebetegügye az 1900. évben (Mental Health Care in Hungary in 1900) (Budapest: Schmidl Sándor Könyvnyomdája, 1901), 11.

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46. Fekete claims that meat was the only raw food supplied by an entrepreneur until 1906, but the Interior Ministry’s report in 1900 already states that English breed Yorkshire pigs were kept at the asylum. In 1899, the pig-population consisted of 500 pigs, out of which the asylum killed 197, and sold 24. Also, alone in 1899, Lipótmez˝ o gained 25,000 eggs from its poultry population. Ministry of Interior (1901), 14; see also Fekete (1968), 79. 47. Food was previously supplied by entrepreneurs which could be disadvantageous to the patients if, for instance, the entrepreneur tried to save money at the expense of food quality. Corruption of different sorts could also occur. Already in 1871, the Minister of Interior ordered Schnirch to only accept written offers for prices and to guarantee free and fair competition between entrepreneurs to avoid causing “considerable damage to the treasury.” See 1871 No. 10,956 decree issued by the Interior Ministry, in Kornél Chyzer, ed., Az egészségügyre vontakozó törvények és rendeletek gy˝ ujteménye. 1854–1894 (Collection of Laws and Decrees Concerning Health Care. 1854–1894) (Budapest: Dobrowsky és Franke, 1894), 20. 48. There were three, later four food-classes. 49. Pándy (1905), 380, 383; Ministry of Interior (1901), 11, 13–14. 50. See József Pólya, Tudnivalók a Pesten felállított privát Elmekórintézetr˝ol (Information on the Private Mental Asylum Opened in Pest) (Pest: Házinyomda, 1842); Ferencz Schwartzer, A Budai Magán Elme- és Ideggyógyintézet tudósítója és tizenkét évi m˝ uködésének eredménye (Report on the Buda Private Mental and Nerve Institute and its 12-year Operation) (Buda, Ny. Bagó M, 1864); “A nagyszebeni Országos Tébolydának az erdélyi királyi f˝ okormányszék 1862-iki 24,044 számú rendeletével kiadott alapszabályai”, in Chyzer (1894), 2; Alapszerkezet (1868?), 3, and Hírdetmény a budai magyar királyi országos tébolyda megnyitását illet˝oleg (Announcement Concerning the Opening of the Buda Hungarian Royal National Lunatic Asylum) (Buda, 1869). 51. See 1898 No. 31,017 decree issued by the Interior Ministry, in Chyzer (1900), 425. 52. Ministry of Interior (1901), 15. 53. See also, for instance, the 1896 No. 62,088 sentence passed by the Budapest Royal Criminal Court in a case of mental patient

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abuse by a nurse, in János Kampis, ed., Az egészségügyre vontakozó törvények és rendeletek gy˝ ujteménye. 1905–1912 (Collection of Laws and Decrees Concerning Health Care. 1905–1912) (Budapest: Dobrowsky és Franke, 1913), 538. 54. See the 1898 No. 20,9419 decree issued by the Interior Ministry, in Chyzer (1900), 414. 55. See the 1900 No. 60,787 decree issued by the Interior Ministry, in Kampis (1913), 69–70. From 1912, a special nurse-training program was introduced at Lipótmez˝ o. See Fabinyi (1922), 249. Comprehensive books containing instructions for nurses employed at public hospital mental wards in Budapest appeared in 1911 and 1916, see Utasítás a székesf˝ovárosi közkórházi elmebeteg osztályon alkalmazott ápolók és ápolón˝ok számára (Directive for Male and Female Nurses Employed at the Mental Illness Wards of the Capital’s Public Hospitals) (Budapest: Házinyomda, 1911) and Utasítás a székesf˝ovárosi közkórházi elmebeteg osztályon alkalmazott ápolók és ápolón˝ok számára (Directive for Male and Female Nurses Employed at the Mental Illness Wards of the Capital’s Public Hospitals) (Budapest: Székesf˝ ováros Házinyomdája, 1916). 56. Fekete (1968), 80. 57. See the 1893 No. 57,084 decree issued by the Interior Ministry, in Chyzer (1894), 815. The ministerial decree was a response to Niedermann’s own initiative to set up the charity fund which was to be managed by a sister or brother of charity in order to ensure that the relatives’ donations to cover the patients’ personal needs are properly managed. For this purpose, the decree allowed the employment of an additional sister/brother of charity who was paid from the 3% handling charge. The rest of these charges were separated for organised holidays and amusements of the poorest patients. 58. Ministry of Interior (1901), 15–16. 59. See, among others, István Thewrewk, “Magyarország elmebetegügye” (Mental Health Care in Hungary), Vasárnapi Újság (Sunday News), October 30, 1904, 747–748. 60. See Henrik Hollán, Adatok és szemelvények a Szent Rókus Közkórház és fiókjai alapításának és fejl˝odésének történetéb˝ol (Data Concerning the History of the Foundation and Development of

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Saint Roch Public Hospital and Its Wards) (Budapest: Medicina Könyvkiadó, 1967), 83. 61. Fabinyi (1922), 249. 62. Pándy (1905), 381. 63. Fabinyi (1922), 249; Epstein (1922), 400. 64. According to the reliable sources by Fabinyi and Epstein, Salgó was the main supporter of both hydrotherapy and bed treatment. According to Fekete (who, unfortunately, never gives his sources), Bolyó started the bed-treatment in 1890. See Fekete (1968), 79– 80; Fabinyi (1922), 249; Epstein (1922), 400. See also: Gusztáv Oláh, Az elmebetegápolás különös tekintettel Magyarország elmebetegügyére (The Care of Mental Patients with Special Reference to Hungary) (Budapest: Pesti Könyvnyomda R.T, 1889). 65. Pándy (1905), 382. 66. Ministry of Interior (1901), 12. 67. Fekete (1968), 79. 68. See entry on Konrád in József Szinnyei, Magyar írók élete és munkái, Vol. 6 (Budapest: Saád-Steinensis, 1908), 927–928. 69. Fekete (1968), 85–86. 70. See below. 71. See a brief introduction on its history in Western Europe in Chapter 2. Also see relevant chapters on the asylum era in Edward Shorter, A History of Psychiatry from the Era of the Asylum to the Age of Prozac (New York: Wiley, 1997); Roy Porter, Madness. A Brief History (Oxford: Oxford University Press, 2002). On the Hungarian story of the introduction of no-restraint system in psychiatric institutions, see: Ferenc Pisztora, “A’no-restraint’ és az’open-door’ irányelveinek megvalósítási kísérletei és értékelése a hazai pszhictriában” (Attempts to Introduce the Principles of ‘No-Restraint’ and ‘Open-Door’ in Hungarian Psychiatry and their Assessment), Az Országos Orvostörténeti Könyvtár Közleményei (Publications of the National Library for the History of Medicine) 145–146 (1994): 29–53. 72. Ödön Blum, “Fejl˝ od˝ o állapotban lév˝ o és nem közveszélyes elmebetegek elhelyezése” (The Housing of Improving and NonDangerous Mentally Ill Patients), Gyógyászat (Medicine) 15 (1899): 228. 73. László Epstein, “Az elmebajok megítélése hajdan és most” (The Perception of Mental Illness Today and in the Past).

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Természettudományi Közlöny (Natural Scientific News) 44 (1912), 537; Jakab Salgó, “Hozzászólás Oláh Gusztáv: ‘Referátum az elmebetegkezelés újabb elveir˝ ol’ cím˝ u el˝ oadásához” (Comments on the lecture ‘Report on The Novel Principles of the Treatment of Mental Patients’ by Gusztáv Oláh), in Az 1902. évi október 26-án és 27-én Budapesten tartott Második Országos Elmeorvosi Értekezlet munkálatai (Proceedings of the Second National Alienist Congress, Held in Budapest, on 26–27 October 1902), ed.László Epstein (Budapest: Schmidl Sándor Könyvnyomdája, 1903b), 127–128. 74. Gusztáv Oláh, “Referátum az elmebetegkezelés újabb elveir˝ ol” (Report on The Novel Principles of the Treatment of Mental Patients), in Az 1902. évi október 26-án és 27-én Budapesten tartott Második Országos Elmeorvosi Értekezlet munkálatai (Proceedings of the Second National Alienist Congress, Held in Budapest, on 26– 27 October 1902), ed.László Epstein (Budapest: Schmidl Sándor Könyvnyomdája, 1903a), 121–127; 126. 75. László Epstein, “Az elmebetegek intézeti gyógykezelésének újabb irányairól” (On Novel Directions in the Institutional Treatment of the Mentally Ill), Gyógyászat (Medicine) 47 (1907): 800. 76. Feldhof (built in 1872) was planned for 300 patients, but in 1878 it already housed 412 patients, in 1880: 516. See chapter on Graz in Renate Hauser, “Sexuality, Neurasthenia, and the Law: Richard von Krafft-Ebing (1840–1902)” (PhD thesis, London University, 1992). 77. See Hauser (1992), chapter on Graz. 78. See Pándy (1905); Zombory (1867), 680; Vasárnapi Újság (1869), 325, 328. 79. Fabinyi (1922), 249; Epstein (1922), 400; Epstein (1897a), 580– 583. 80. See Fabinyi (1922), 249; Epstein (1922), 400. According to Pándy, they were only closed and rebuilt to serve different functions by Konrád in 1906. See Pándy (1905), 369. 81. Ministry of Interior (1901), 11. 82. László Epstein, “A»no-restraint« határáról” (On the Limits of»no-restraint«). Gyógyászat (Medicine) 48 (1897b): 736. 83. Epstein (1897b), 736. 84. Gusztáv Verubek, “A budapesti-lipótmezei m. k. állami elmegyógyintézet 40 évi története, 1868–1908” (The 40-Years History

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of the Hungarian Royal State Mental Insitute of BudapestLipótmez˝ o, 1868–1908), Gyógyászat (Medicine) 34 (1909): 571; 39, 654; 40, 669; 41, 685; 42, 702; 43, 721. 85. Epstein (1907), 800. 86. Károly Lechner “Az elmebetegkezelés és újabb elvei” (The Novel Principles of the Treatment of Mental Patients), in Az 1902. évi október 26-án és 27-én Budapesten tartott Második Országos Elmeorvosi Értekezlet munkálatai (Proceedings of the Second National Alienist Congress, Held in Budapest, on 26–27 October 1902), ed.László Epstein (Budapest: Schmidl Sándor Könyvnyomdája, 1903), 108. 87. Lechner (1903), 108. 88. Salgó (1903), 127–128. 89. Epstein (1907), 800. 90. These conclusions are drawn based on hundreds of case histories I read in Lipótmez˝ o psychiatric institute’s archive in 2002. Unfortunately, the archive disappeared since then after the psychiatric institution was closed in 2007, no one could give me clear information on where the historical files are kept now. 91. Károly Bolyó, “Utazási napló-töredékek” (Fragments from a Travel Journal) Gyógyászat (Medicine) 48 (1862): 986. 92. Epstein (1897b), 736. 93. Ibid. 94. Jen˝ o Konrád, Az elmekórtan gyakorlatilag fontos tételei, tekintettel a közigazgatásra. Gyakorló és tiszti orvosok számára (The Practical Aspects of Psychiatry, with Special Emphasis on State Administration. For Practicing and Military Physicians) (Budapest: Dobrowsky és Franke, 1915), 112. 95. Epstein (1907), 800. 96. See Ministry of Interior (1901), 14–16; Fekete (1968), 79. 97. Ministry of Interior (1901), 12. 98. Pándy (1905), 383. 99. See Pólya (1842); József Pólya, Bemerkungen und Statuten der zu Pesth errichteten Privat-Heilanstalt für Gemüths- und Geisteskranke (Pesth: Landerer und Heckenast, 1844); Schwartzer (1864). 100. Chyzer (1894), 2. 101. Ibid., 4. However, the exclusion of epileptics remained only a principle, since statistical tables concerning the patient population

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at Nagyszeben asylum show that epileptic patients were indeed admitted. See tables in Pándy (1914); see also discussed below. 102. See Alapszerkezet (1868), 3; Hírdetmény (1869). 103. See discussed above and in Chapter 2. 104. Chyzer (1894), 4. According to the Lipótmez˝ o documents, the former doctor of the patient had to include a statement concerning curability and dangerousness. See Alapszerkezet (1868), 6, also see Hírdetmény (1869), 1. 105. See paragraph 72 in Article X of the 1876 XIV Public Health Care Act, in Chyzer (1894), 81–82. 106. See its criticism by psychiatrists at the 1900 National Alienist Congress, discussed below. An 1893 decree issued by the Minister of Interior and addressed to the director of Lipótmez˝ o clarified that all doctors with public office qualified for giving certificate on the patient’s mental state (which formed the basis of temporary admission), including: practitioners who only had surgeon diploma; university teachers, privatdozents and teaching assistants in case they studied mental pathology; honorary regional doctors; hospital directors and chief doctors; in case of mentally disordered soldiers, army doctors. See 1893 No. 59,847/82 decree issued by the Interior Ministry, in Chyzer (1894), 816–817. 107. See 1874 No. 12,747 decree issued by the Interior Ministry, in Chyzer (1894), 38–39. 108. The questionnaire demonstrates a particularly refined view of mental disorders. See 1874 No. 12,747 decree issued by the Interior Ministry, in Chyzer (1894), 38–39. 109. See discussed in detail below. Also see, for instance, the 1889 No. 18,960 decree issued by the Interior Ministry, in Chyzer (1900), 533–534; the 1903 No. 10,538 decree issued by the Interior Ministry, in Kornél Chyzer, ed., Az egészségügyre vontakozó törvények és rendeletek gy˝ ujteménye. 1900–1904 (Collection of Laws and Decrees Concerning Health Care. 1900–1904) (Budapest: Dobrowsky és Franke, 1905), 373–381. 110. See Alapszerkezet (1868), 6; Hírdetmény (1869), 1–2; Chyzer (1894). 4–5. 111. See Hírdetmény (1869), 3; Chyzer (1894), 4–5. 112. See discussed in Chapter 2. For the 1875 III Act concerning the cover of costs of public health care provision, see Chyzer (1894), 49–51.

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113. 1870 No. 16,431 decree issued by the Interior Ministry, in Chyzer (1894), 22. 114. 1871 No. 31,100 decree issued by the Interior Ministry, in Chyzer (1894), 23. 115. 1871 No. 26,949 decree issued by the Interior Ministry, in Chyzer (1894), 19. 116. 1871 No. 31,100 decree issued by the Interior Ministry, in Chyzer (1894), 22–23. 117. 1895 No. 102,463 decree issued by the Interior Ministry, in Chyzer (1900), 158. See also, for instance: the 1899 No. 31,708 decree issued by the Interior Ministry, in Chyzer (1900), 594. 118. 1888 No. 25,960 decree issued by the Interior Ministry, in Chyzer (1900), 423–424. 119. See 1889 No. 43,881 decree issued by the Interior Ministry, in Chyzer (1900), 548, and 1890 No. 86,267/89 decree issued by the Interior Ministry, in Chyzer (1900), 593. 120. See 1889 No. 43,881 decree issued by the Interior Ministry, in Chyzer (1900), 548. 121. See 1889 No.18,960 decree issued by the Interior Ministry, in Chyzer (1900), 533–534. 122. See paragraph 8 in the 1875 III Act concerning the cover of costs of public health care provision in Chyzer (1894), 49–51, as well as paragraph 71 in Article X of the 1876 XIV Public Health Care Act, in Chyzer (1894), 81–82. 123. See 1889 No. 43,881 decree issued by the Interior Ministry, in Chyzer (1900), 548. 124. See 1889 No. 43,881 decree issued by the Interior Ministry, in Chyzer (1900), 548. 125. See 1885 No. 5,845 decree issued by the Interior Ministry, in Chyzer (1894), 328. 126. See 1903 No. 10,538 decree issued by the Interior Ministry, in Chyzer (1905), 373–381. 127. See paragraph 73 in Article X of the 1876 XIV Public Health Care Act in Chyzer (1894), 81–82. 128. See Babarczi Schwartzer’s comments to the presentation by Jen˝ o Konrád, “Az elmegyógyintézetekben elhelyezett betegek elmebetegségének és az abból való kigyógyulásnak megállapításáról” (On Judging the State of Mental Illness and Its Cure in Case of Patients Treated in Mental Institutions), in Az 1900. évi október

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28–29-én Budapesten tartott Els˝o Országos Elmeorvosi Értekezlet munkálatai (Proceedings of the First National Alienist Congress, Held in Budapest, on 28–29 October 1900), edited by László Epstein (Budapest: Pallas, 1901), 62. 129. See Chyzer (1894), 4–5. 130. See paragraphs 7 and 11 in Alapszerkezet (1868?), 6–7. 131. See 1877 XX Act on guardianship, in Chyzer (1894), 167. 132. See 1885 VI Act modifying and complementing the 1877 XX Act on guardianship, in Chyzer (1894), 325. 133. See 1877 No. 20,194 decree issued by the Interior Ministry, in Chyzer (1894), 167. 134. See 1881 No. 10,225 decree issued by the Interior Ministry, in Chyzer (1894), 239. 135. Konrád (1901), 53–64. 136. See Ottó Babarczi Schwartzer, Közigazgatási elmekórtan (Administrative Mental Pathology) (Budapest: Franklin, 1897). 137. See Babarczi Schwartzer’s response to Konrád’s presentation, Konrád (1901), 62. 138. A director’s verdict that the patient was insane was sufficient for courts to place the patient under guardianship, since it counted as “an expert opinion.” The same applied to freeing someone from guardianship and acquitting from the state asylum. Konrád added that in obvious cases of insanity, it did not raise problems. But in cases of some nervous diseases where mood changes constituted the predominant symptoms, the misinterpretation of the disease was frequent. See Konrád (1901), 56. 139. Konrád criticised the law salary of psychiatrists which exposed them to “temptations,” but he quickly added that “the high moral standards of the profession” defended psychiatrists from “mistakes.” He concluded that psychiatrists had to “refuse this uncontrolled power” which only saved money to the state while it brought accusations and caused damages to the profession. Konrád (1901), 53, 57. 140. See Jakab Fischer’s response to Konrád’s presentation, Konrád (1901), 60. 141. See 1876 XIV Public Health Care Act, in Chyzer (1894), 81–82, and 1898 No. 133,000 decree issued by the Interior Ministry, in Chyzer (1900), 518–561.

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142. See Kálmán Pándy’s response to Konrád’s presentation, Konrád (1901), 61. 143. According to Pándy, the same applied when directors should have initiated to free a patient from guardianship after recovery from mental illness. See ibid. 144. See Pándy’s response to Konrád (1901), 61. 145. Ibid. 146. See Zsigmond Telegdi’s response to Konrád’s presentation, Konrád (1901), 63. 147. See Henrik Szigeti’s response to Konrád’s presentation, Konrád (1901), 63. 148. See Kálmán Glósz’s response to Konrád’s presentation, Konrád (1901), 63. 149. Konrád (1901), 58–59. 150. See Konrád and Jakab Salgó’s response to Konrád’s presentation, Konrád (1901), 57, 60. 151. See Pándy’s response to Konrád’s presentation, Konrád (1901), 60. 152. Laufenauer believed that patients should be placed under guardianship once they were permanently admitted to a closed institution. See Laufenauer’s response to Konrád’s presentation, Konrád (1901), 59–60. 153. See Ern˝ o Moravcsik’s response to Konrád’s presentation, Konrád (1901), 63. 154. See Salgó’s response to Konrád’s presentation, Konrád (1901), 60. 155. See Ottó Babarczi Schwartzer’s response to Konrád’s presentation, Konrád (1901), 62. 156. Konrád (1901), 54. 157. Ibid., 55.

CHAPTER 5

The University Clinic and the Birth of Biological Psychiatry. Academic Research, Teaching and Therapy from the 1880s

This chapter deals with another type of institution that was crucial for certain developments to take place in psychiatry: the Department of Mental Health and Pathology (1882) and its related mental and nerve clinics (hereafter sometimes referred to as psychiatric clinic) which enabled the introduction of proper university teaching in mental and nerve pathology as well as the rise of neuro-scientific academic research. Compared to the micro-society of the asylum, the university psychiatric clinic was a very different “small world.” It functioned as an “obligatory passage point” for medical students, academic researchers, mental and nervous patients as well as criminals suspected of mental derangement (concerning the latter, most of these criminals were compulsorily brought in by the police for mental observation). Its threefold function constituted of teaching, research and therapy, the relationship of which was complex and fraught with tensions. This chapter captures the rise of neuro-scientific research in Hungarian psychiatry from the 1870s and reconstructs distinct research practices (brain dissection, histological laboratory work, microscopic observation and clinical experimental research) that became emblematic of the psychiatric clinic. First, I briefly discuss developments in nineteenth-century medicine that made academic psychiatry flourish in Europe, especially in German-speaking countries. Significant changes in patho-anatomical © The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 E. Lafferton, Hungarian Psychiatry, Society and Politics in the Long Nineteenth Century, Mental Health in Historical Perspective, https://doi.org/10.1007/978-3-030-85706-6_5

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research and clinical medicine in Vienna are given special emphasis. Then I elaborate on the history of setting up the Department of Mental Health and Pathology at the Budapest Medical Faculty and discuss the characteristics and functions of the related psychiatric clinic among other mental institutions in the capital city. I demonstrate laboratory research through the neuro-pathological investigations by Laufenauer and Schaffer whose work and life are also presented as paradigmatic of this new type of researcher and single out hypnosis studies to briefly illustrate experimental clinical research.

Self-Perception. Teaching and Research in the Making of the Psychiatrist The issue of university teaching in psychiatry had been discussed by doctors from the middle of the nineteenth century and gained further significance with the rise of new institutions. In order to secure the recruitment of new generations of psychiatrists, to set alternative career patterns and to strengthen the sense of belonging to the same trade, members of the new profession had to gain legitimacy within the Pest Medical Faculty and work out a curriculum to define the expert field of psychiatry. Already in the 1840s and 1850s, the first private asylum directors, Pólya1 and Schwartzer, realised the importance of psychiatric knowledge and practice for general practitioners since, as the latter argued, they were supposed to at least recognise the earliest signs of mental disease and were in a position of sending these patients in a hospital. General knowledge in the field was also important since, in the process of declaring someone mentally deranged in court, for instance, the state required expert opinion by two general doctors with a medical diploma. Education in mental pathology was meant to include the teaching of how to recognise, judge and cure mental disorders, how to write useful case histories and scientifically founded expert opinions, and how to estimate the curability and dangers of certain mental disorders. Thus, Schwartzer’s 1858 textbook as well as general works in forensic medicine argued for the practical education of doctors in mental pathology.2 In Schwartzer’s mind, his asylum provided adequate patient material for teaching, thus already in the mid-1850s he propagated the establishment of a psychiatric clinic.3 While repeating these concerns from the beginning of the 1870s, the eminent psychiatrist, Károly Laufenauer (1848–1901), stressed another,

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purely scientific aim as well: psychiatry as an exact science was lagging behind because it was not present in university teaching, and there was no possibility for academic research.4 In psychiatrists’ accounts from the turn of the century and beyond, one can find the assumed reasons why psychiatry’s relationship with medicine had been fraught with problems from the beginning of psychiatric professionalisation which presented obstacles in establishing it as a separate medical science. These problems centred around questions of objectivity and the scientific method. In his reflections on the early period of the history of psychiatry in Hungary, Ern˝ o Moravcsik (1858–1924), the most reputable clinician of the period and author of many textbooks in mental pathology and forensic psychiatry, collected the factors that had for long undermined the scientific basis of psychiatry: the nature of mental illness had been misunderstood; the seeming lack of common ties to other medical sciences; its symptomatology that could hardly (or not at all) be founded on anatomy; its core concepts borrowed from philosophy; its specific nomenclature; the fact that, for a long time, there had been no available patient material for clinical research.5 As the eminent alienist and author of a comprehensive textbook on mental illnesses, Jakab Salgó lamented in even as late as 1890: the “fundamental processes of mental disorders are inaccessible, doctors can only judge their progress manifest in the patients’ behaviour, speech, writing, and act.” The psychiatric examination of patients lacked “mechanic methods,” and most of the pathological symptoms were beyond the reach of usual medical examination methods. The pathological manifestations of psychic life were “available not so much to objective definition, but rather to experience-based criticism.” Thus, in Salgó’s mind, it was the “subjective contribution of the patient” that formed the basis for examination, and not “the objective symptoms of organic illnesses that medicine treats in other areas.”6 Similar problems are mentioned by Károly Schaffer in his retrospective assessment of the factors that exiled “psychiatry into ‘splendid isolation’” among the medical sciences for a long time: “the clinical specificity of mental pathology, and the inaccessibility of the ‘psyche’ to clinical measuring instruments and other observing tools” made the science of psychiatry markedly different from other medical sciences.7 Schaffer acknowledged the work of French and German doctors (Esquirol, Magnan, Griesinger and Kahlbaum) who worked on reconstructing the symptomatology of mental diseases. However, in Schaffer’s

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narrative, it was only “with the triumph of pathological and anatomical research” from the 1880s that “the waves of modern currents also reached the lonely island of mental pathology” and made it possible to see the essence of mental disorders in the material lesions of the brain.8 While mental pathology was often dismissed as subjective and lacking hard scientific foundations, Laufenauer believed that, by connecting mental pathology to academic research in neuro-pathology and brain anatomy, this scientific status could be established.9 Moravcsik also admitted the role earlier asylums had played in the history of the discipline. He nevertheless stated that, in this period, “the scientific foundation and further development of psychiatry were connected to the establishment of university clinics,” whose furnishing, equipment and larger doctoral staff made academic research possible in these institutions.10 The resurgence in academic research in the second part of the nineteenth century in Hungary was strongly connected to the newly founded departments and related clinics from the early 1870s.11 In this boom of department foundation and clinic building on the “medical premises” near the Pest Medical Faculty, psychiatry initially did not fare well. With its establishment in 1882, the Department of Mental Health and Pathology was years behind the formation of other modern medical departments in Pest in the 1870s and had to be content with the small clinic or observation ward12 within Saint Roch Hospital. Even this ward was moved some distance away from other university buildings in 1889 which raised difficulties for medical students to attend psychiatric patient demonstrations and observe clinical research. Thus, the move was seen as a fatal blow to teaching in psychiatry. The modern, large and separate psychiatric clinic was finally realised only in 1908 with the second wave of clinic construction in the first decade of the twentieth century, when a brand-new eye clinic, two internal medicine clinics, a surgery clinic, etc. were built.13

The Medical Context of Nineteenth-Century Scientific Psychiatry As I briefly discussed in the second chapter, the context for academic psychiatric expansion was provided by general developments in the medical sciences. From the first decades of the nineteenth century, medicine grew increasingly hospital-based: scientific clinical observation of the living patient with novel instruments and meticulous search for

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lesions in the dead body developed in French hospitals which gave rise to new disease concepts.14 Due to the influence of the new French medicine, the rich clinical material of hospitals was used for medical investigation and teaching throughout Western Europe. During these decades, Viennese and Hungarian medical cultures suffered from political and scientific conservatism, although bedside medicine with devoted patient observation had long been a tradition in these countries.15 From the middle of the nineteenth century, medicine became researchoriented. New forms of practices, such as laboratory and experimental research, came to distinguish modern medical research in different areas, most importantly physiology and chemistry. These developed in statefunded universities and research centres and made use of the technologically advanced microscopy. The reason why from the middle of the century German medical research became superior to the French (and in fact all other national medicines) lies in these countries’ different cultural, political and economic traditions. While scientific-based experimental medical culture grew strong at numerous research centres in German universities, more centralised France failed to create a similar loose network of well-furnished laboratories and advance research. Due to its traditions, British medicine was still mostly practised by private physicians and university research was poorly subsidised in the middle of the nineteenth century.16 At the same time, Vienna, revitalised after three decades of medical conservatism due to comprehensive reforms at the end of the 1840s, regained its leading role as a supreme medical centre in Europe due to the work of a handful of professors and their numerous subsequent disciples around the Bohemia-Moravian-born Carl von Rokitanski (1804–1878).17 The all-powerful Rokitanski was the first freely elected dean of the medical collegium from 1849, chancellor of the Vienna University in 1852–1853, president of the Society of Physicians between 1850 and 1878, and president of the Academy of Sciences between 1869 and 1878. It was also due to Rokitanski that the medical faculties of Graz and Innsbruck were re-established.18 As I pointed out in the third chapter, Rokitanski’s scientific materialism and positivism were in sharp contrast to medical theories and practices prevalent in Vienna, especially the natural philosophical tradition that so strongly marked the work of Hartmann in the field of general pathology and therapy. Rokitanski believed that medical knowledge had to rely on patho-anatomical findings, therefore he saw the task as.

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first … sorting the facts scientifically on a purely anatomical basis and thereby creating the subject of general pathological anatomy which would justify its separate existence as such … second, demonstrating the applicability of the facts and their utilisation for diagnosis in live patients.19

He was allegedly the greatest dissector of his time, having performed about 60,000 autopsies during his life.20 Believing that pathological anatomy not only formed the basis of research but also of “all medical treatment,” he made pathological anatomy a compulsory subject at the Vienna Medical Faculty in 1844.21 He was called the Linné of pathological anatomy after his separation of definite types of diseases with their individual characteristics.22 Rokitanski, however, was an advocate of macroscopic pathology rather than microscopic investigation. Microscopic and experimental research was established by others in Vienna, the most important advocate was Joseph Engel, with the strong support of Rokitanski. Engel lectured from the early 1840s on pathological histology, and according to Lesky, Vienna was the first in German lands to appoint a Chair of Histology in 1853.23 Laboratory research was further strengthened by new investigations into cellular pathology. Its most eminent Berlin and later Würzburg expert was Rudolf Virchow (1821–1902) who explained diseases by abnormal changes in the cells and disturbances in the organism’s cellular structures.24 With energetic biomedical research beginning in cellular pathology in Vienna at the end of the 1850s, laboratory science was firmly established within the Viennese Medical Faculty.25 In the field of internal medicine, clinical medicine came to the fore, and the correlation of the anatomical basis and clinical symptoms of diseases was studied under the direction of Joseph Skoda (1805–1881). He is considered the founder of modern physical diagnostics and “anatomical clinicism” in Vienna.26 Most eminent clinicians and pathologists of the period were trained under Rokitanski and Skoda. Their influence reached the Pest Medical Faculty through the appointment of several of their Austrian and Hungarian students at the dissection and internal medicine departments, as well as through scholarly contacts and visits of established Hungarian professors to Vienna. It was within this context of developments in clinical medicine and laboratory/ experimental research that German and Austrian dominance in academic and biological psychiatry was established. The most influential figure of university psychiatry is undoubtedly the eminent Wilhelm

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Griesinger (1817–1868), whose 1845 book published under the title Pathologie und Therapie der psychischen Krankenheiten (Pathology and Therapy of Mental Disorders) announced that mental disorders were diseases of the brain, which became the central tenet of numerous psychiatrists in Europe in the second part of the nineteenth century. Griesinger’s idea that mental disorder was only a symptom of brain disease led to energetic research into the underlying anatomical cause of psychiatric illnesses. Griesinger’s most eminent follower in the next generation was his successor in Berlin, Carl Westphal (1833–1890).27 Griesinger’s early counterpart in Vienna was Joseph Dietl. In line with the particular concerns of the Rokitanski school, Dietl’s 1846 treatise Anatomische Klinik der Gehirnkrankheiten (Anatomical Clinic of Brain Disorders) attempted to relate clinical and patho-anatomical evidence: the chaotic symptoms of cerebral diseases to their related material lesions in the brain, thus giving “objective” diagnosis of diseases as meningitis, encephalitis, etc.28 From the generation active from the 1860s, Maximilian Leidesdorf’s (1816–1889) work was strongly influenced by Griesinger and brain anatomy, but the most significant scientists were the Dresden-born neuro-pathologist, Theodor Meynert29 (student and patronised by Rokitanski), who advanced neuro-anatomical research in Vienna from the late-1860s, and Carl Wernicke (1848–1905), researcher in cerebral localisation.30 Within psychiatry, this optimistic turn towards the university clinic and academic research was also due to two important reasons. One was the realisation of the inadequacies and inefficiency of public asylums. However, the acceptance of these new forms of research (often conducted in clinics set up in asylums) was difficult for the older generation of alienists who professed a more patient-centred view and sometimes explicitly criticised such research as disadvantageous to mental patients. In both Germany and Austria, the relationship between alienists and the emerging generation of university psychiatrists was troubled.31 Differences between the perspectives and professed ideals of asylum doctors and university psychiatrists were also manifest in Hungary, but in the initial phase, no such hostility is apparent as in other countries. The other reason for establishing university psychiatry consisted of internal professional needs: professionalisation necessitated the foundation of university departments, the establishment of specialised training and career tracks and the production of psychiatric knowledge. Early lecturing in psychiatry in German lands began by Johann Heinroth in

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Leipzig in 1811 and was followed by a few similar sporadic initiatives. These were, however, short-lived and did not yet live up to the new standards of combining departmental lecturing with practical patient demonstrations at a connected psychiatric clinic. This ideal of linking the clinic to the psychiatric department where both research and teaching could be pursued was realised by Griesinger in Berlin in 1865, and subsequently became the overriding pattern in the Germanic world.32 The outbreak in this respect was not immediate. According to Engstrom, in the mid-1870s, academic clinics as the sites of scientific research still did not exist, academic psychiatry had virtually no tradition.33 In Austria, it was Leidesdorf who established clinical-psychiatric university education. Lectures in psychiatry were first given in Prague by Riedl in 1841, in Vienna by Feuchtersleben and Viszanik from 1844, Karl Flögl from 1848 and by Leidesdorf from 1856. In a petition to the Ministry of Education in 1869, Leidesdorf requested the establishment of a psychiatric clinic at the mental asylum (the Imperial Royal Institution for the Treatment and Care of the Insane opened in 1853 and directed by Riedl34 ). There was a mental observation ward for patients suspected to suffer from mental disorder at the General Hospital since 1828, which was led by Viszanik from 1853 till 1869. Mental observation wards at hospitals had the advantage of providing new cases due to the flow of patients as opposed to mental asylums which had a more stable clientele with numerous hopeless cases. When Viszanik retired, the Medical Faculty suggested the establishment of two psychiatric clinics, one at the mental asylum, and the other at the General Hospital with Leidesdorf as director. To the disappointment of many, however, the Ministry decided to set up only one psychiatric clinic at the mental asylum where Theodor Meynert was appointed as director in 1870.35 After certain controversies,36 a second psychiatric clinic was established at the General Hospital headed by Leidesdorf in 1875.37 The first psychiatric department was thus set up under Meynert in 1870 and was followed a second chair in psychiatry five years later. In Hungary, the psychiatric department and clinic was set up a decade later, and due to the endeavours of Laufenauer, psychiatric teaching and scientific research became possible in Hungary.

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Károly Laufenauer and the Establishment of the Department of Mental Health and Pathology and Its Related Clinic [Laufenauer] represented remarkable intellectual value and flexibility, thanks to which the small boat of Hungarian clinical psychiatry did not sink in the sea of indifference, in spite of strong counter-currents; although unfavourable winds cast it ashore on a bleak coast for a long time.38

It was the eminent psychiatrist, Károly Laufenauer (1848–1901) who succeeded in including the systematic study of mental pathology into the medical curriculum and who established neurological clinical practice as well as neuro-pathological and histological research in Hungary.39 Laufenauer was born in Székesfehérvár (a town not far from Pest) in 1848, the year of the revolution, and died suddenly in 1901, at the age of 53.40 He went to elementary and high school in Székesfehérvár and then studied medicine at the Pest Medical Faculty. Born into a bourgeois family of modest means, he had to teach during his university years in order to support himself, which might have contributed to his later becoming a very hard-working and tireless researcher and practitioner. Parallel to his medical studies, he found time even to publish short stories and articles.41 After receiving his medical diploma in 1873, Laufenauer worked at the Schwartzer asylum for three years. It was here that he fell in love with psychiatry and decided to dedicate his life to clinical practice, teaching and research. In 1875–1876 he spent a year with a scholarship abroad, studying with great figures of the German language schools of neurophysiology: Meynert in Vienna (brain histology, normal and pathological anatomy of the central nervous system, and the methods of its micro- and macroscopic observation) and Westphal in Berlin (neuro-pathology).42 Returning to Hungary, he worked at Lipótmez˝ o mental asylum for three years. While some of Schwartzer students made their careers in asylums as alienists, Laufenauer did not neglect neuro-pathology and continued histological research even during the years he worked at Lipótmez˝ o as an assistant doctor. In 1881, he left the asylum and continued to practise at Saint Roch Hospital as the doctor of the mental observation ward.43 His early career in different types of institutions thus provided him with varied experiences with distinct psychiatric practices and ways of looking at mental illness.

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Laufenauer became privatdozent of mental health and pathology in 1878. In 1882, the Minister of Religion and Education, Ágoston Trefort, appointed him Professor Extraordinarius to enable him to become the head of the newly founded Department of Mental Health and Pathology at the Pest Medical Faculty, for which Laufenauer had tirelessly lobbied for since the 1870s.44 In 1891, Laufenauer became full professor (Professor Ordinarius ) of mental pathology and neurology, and was elected corresponding member of the Hungarian Academy of Sciences in 1898.45 At a time when several new medical sub-disciplines emerged and different medical professional groups competed for recognition and authority, Laufenauer endeavoured to secure psychiatry and neurology an increasingly prestigious place within the medical sciences. Although mental pathology was first introduced at the Pest Medical Faculty in 1847 as a non-compulsory subject,46 there was no systematic psychiatric teaching, only sporadic lectures by privatdozents: Ferencz Schwartzer from 1860/1861,47 Károly Bolyó from 1866/1867 and Laufenauer from 1878.48 Gyula Niedermann (from 1865) and Ottó Babarczi Schwartzer (from 1885) lectured on forensic psychiatry at the Law Faculty of the Budapest University.49 For Laufenauer, the original model for the establishment of the psychiatric department and clinic was Griesinger’s ideal of a not-too-large clinic connected to the department in the vicinity of other medical clinics, collecting mostly acute cases for patient presentation and undertaking academic research. This was implemented at many German universities in the 1870s and the following decades.50 Since a separate modern clinic was not realisable for financial reasons until 1908, Laufenauer was forced to compromise with the cheaper version of using a hospital ward for teaching purposes (as most early European examples also show, see below). The story of the establishment of the psychiatric university department is rather complicated. Members of the Budapest Medical Faculty already proposed it in 1873. It, however, necessitated setting up a clinic attached to it. But the only institution these advocators saw as adequate to provide patient material and practice for students at the time was Lipótmez˝ o asylum, that they found was too far out in the outskirts of Budapest, where students had neither time nor money to travel three times a week during an entire semester. The whole idea of the department thus had to be postponed.51 The Schwartzer asylum strangely does not seem to have emerged as an alternative to provide patients for the lectures. Saint

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Roch Hospital (a municipal institution) was also not an option, since the hospital managers at the city council had a notoriously bad relationship with the university. They had been adverse to the idea of mixing traditional hospital practices with the teaching functions of a university clinic, mostly for financial reasons.52 To prove that the clinic would not have been a burden to the hospital, Laufenauer later emphasised that the expert direction of the mental clinic (mental observation ward) did not only enhance the reputation of the hospital, but was also financially beneficial, since the professional staff was paid by the university. Furthermore, in addition to his teaching duties, the assistant doctor was compelled to assume the responsibilities of the general hospital doctor and thus was a help to the general hospital staff.53 For long, the cause of the university mental clinic depended on the attitude and rejection by town authorities and hospital management. In 1881, a general mental observation ward, consisting of two rooms with 50 beds, was opened at Saint Roch Hospital and began to function under the direction of Laufenauer. (This psychiatric observation ward connected to the university through the person of Laufenauer but physically integrated into Saint Roch Hospital was not the first mental observation ward at the hospital. By this time, the hospital had had such a ward functioning for 20 years.54 ) It belonged to the internist Károly Kétly’s large ward of internal medicine and nerve-diseases. Due to the continuous endeavours by Lajos Markusovszky, Laufenauer and others to establish the department, and after the final approval of the city council which relinquished the mental observation ward for use to the Budapest Medical Faculty, most of the obstacles were removed. In 1882, the Parliament voted a budget for the creation of the Department of Mental Health and Pathology at the university.55 Laufenauer was given an assistant doctor and a “servant,” the hospital provided the mental observation ward with a laboratory and the assistant doctor with lodging at the hospital. From 1883 to 1889, the assistant doctor’s position was filled by Ern˝ o Moravcsik who thus gained his experience alongside Laufenauer. In 1884, the director of the hospital, Lajos Gebhardt, expanded the mental observation ward with a small nerve clinic which consisted of a room with 12 beds for nervous patients and a small laboratory for neuro-pathological research placed under Laufenauer. In 1886 and 1888, two new paid positions were opened: a research assistant and an assistant doctor joined the department.56 In 1887, Károly Schaffer

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filled the former position at the nerve clinic (still as a student in his last year), and from 1890 to 1895 continued as an assistant doctor. After the death of Laufenauer in 1901, his students and close colleagues, Moravcsik and Schaffer were nominated for the vacant position. I will discuss what were at stake with the nomination at the end of this chapter, here it suffices to say that Moravcsik came out victorious from the competition. In the coming years, following Laufenauer’s dream, Moravcsik ardently lobbied for a new clinic which eventually opened in a splendid, modern, large and separate building in 1908. (For more on Moravcsik’s role in establishing forensic psychiatry in Hungary, the foundation of the National Observation- and Mental Hospital for Persons in Detention and Prisoners, and the complex integrative function of the new clinic opened in 1908, see Chapter 6.) Laufenauer’s Observation Ward and the Mad Strangler at Saint Roch Hospital To demonstrate the complex functions of the mental observation ward, I created a table based on admission and discharge statistics of the year 1885 (taken from Orvosi Hetilap). Laufenauer’s ward statistics are compared with those of a similar sized observation ward from the other part of the Dual Monarchy: Richard von Krafft-Ebing’s psychiatric clinic in Graz in the year 1887. While most parameters are very similar, a unique feature of the Budapest clinic becomes apparent in the comparison. From Table 5.1, the constant flow of patients is immediately visible. Unlike the asylums, the ward treated outpatients as well, most probably suffering from nervous problems57 (there were 183 outpatients at Laufenauer’s ward in 1885, just a year after the small nerve clinic was added to the observation ward; while years later, their number was above 600– 800). Krafft-Ebing’s psychiatric clinic can be compared to Laufenauer’s both in size and in some of the functions served. Both doctors had a similar work-load and both used their patients for teaching purposes and demonstrations. While Krafft-Ebing had two assistants to help him with his work, Laufenauer had only one for many years. According to the numbers, the percentage of cured was somewhat higher in Budapest (18% as opposed to 14%), while death-rate was worse in Budapest than at the Graz clinic. The table shows, however, a significant difference between the two wards: the ratio of transfer was considerably higher at the Budapest

844

Krafft-Ebing’s ward in Graz, 1887b

145

18.0% 123

14.0%

100.0% 883

100.0%

Cured

813

Total

20.0%

23.0% 176

188

Improved

41.0%

45.0% 362

365

Not improved

4.2%

7.6% 37

59

Died at the ward

15.0%

135

4.8%d 50

5.6%

[327]c

Referred to other institution

39

Remained for next year

Sources a These admission and discharge statistics were published by Károly Laufenauer, “Betegforgalom a Megfigyel˝ oosztályon a Rókus Kórházban” (Patient Admissions and Discharges at the Observation Ward at Saint Roch Hospital in 1885), Orvosi Hetilap (Medical Weekly) 5 (1886), 134–135 b The figures related to Krafft-Ebing’s clinic are from Renate Hauser, “Sexuality, Neurasthenia, and the Law: Richard von Krafft-Ebing (1840–1902)” (PhD thesis, London University, 1992) c This number includes those already included in the numbers of cured-improved-not improved categories. Therefore, it does not influence the percentages d Laufenauer provided the numbers based on which I constructed the table. If we add up Laufenauer’s numbers, we only get 796, which means that 17 patients are “lost” somewhere among his numbers

39

756

New admissions

Lauffenauer’s 57 ward at Saint Roch Hospital, 1885a

Remained from previous year

Table 5.1 Patient admissions and discharges at Laufenauer’s observation ward at Saint Roch Hospital in 1885 and Krafft-Ebing’s observation ward in Graz in 1887

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institution. While only 15% of the patients were transferred from KrafftEbing’s ward, Laufenauer sent 40% (327 out of 813 patients treated throughout the year) to other institutions, which suggests that the clinic was a centre for redistribution of patients mostly collected from the capital.58 From these 327 patients, Laufenauer regarded 143 (44%) as improved or curable, thus he sent them to Lipótmez˝ o state asylum, and 184 (56%) as incurable.59 Out of the latter, 81 were transferred to the mental ward of the Hospitaller Order’s Hospital in Óbuda, 78 to Angyalföld state asylum, 8 to the poorhouse in Budapest and 17 to other wards at the hospital. This management of patients through transfer confirms that there existed a “division of labour” (as to the “quality” of patient population treated) and a systematic distribution of patients and functions within the network of mental institutions in the capital city. Considering the large annual number of patients and the small number of beds, one can conclude that the average time patients spent at the ward was considerably shorter than the time spent at the asylum. While all chronic cases were quickly transferred, it was mostly the acute psychiatric cases (including forensic cases) who were retained and used for teaching at the ward. Numerous patient presentations at the Royal Society of Budapest Physicians as well as articles in learned medical journals suggest that the scientifically most interesting cases were kept at the ward and used for further research and experimentation.60 It is clear that Laufenauer’s ward was not equipped for the longterm treatment of numerous patients. While there is no available data concerning the average length of hospitalisation at the ward, 57 patients remained from 1884 while 756 were newly admitted at the ward that was furnished with about 60 beds.61 Most of the conditions that alienists and supporters of the therapeutic asylum regarded as important in fighting mental illness within the walls of the asylum were naturally not found in the small university clinic. Within a busy hospital in the middle of the city, there were no gardens and parks where the patients could enjoy amusements in all seasons. Work therapy considered crucial for improvement was impossible, and the core idea of the asylum—separation of the individual from the hectic outside world and placing him/her in a community of similarly inflicted people where the doctors’ only concern is to bring about a cure with long-term treatment—also proved unrealisable in the clinic (although large asylums also failed to live up to some of these ideals by the 1880s).

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In Moravcsik’s recollections, Laufenauer’s ward was a “model for order and cleanliness.” Laufenauer often spent the night taking care of his patients, “he was deeply concerned about their future, and did everything to improve their conditions. Like a father, he took care of his patients facing several problems even after they left his ward.”62 The picture of his ward as the “model for order and cleanliness” seems to be a strong exaggeration (motivated perhaps by Moravcsik’s reverence for his late teacher and colleague), especially in comparison with Laufenauer’s own views of the ward (see below). Moravcsik himself admitted that the ward soon became overcrowded, and since the hospital had to accept all patients brought in by the police for mental observation, patients often slept in the corridors.63 The rather chaotic conditions are also confirmed by what we can infer from the daily press. Daily papers bear witness to the fact that many of the odd, mad, sick, criminal and deviant people walking the streets of Budapest ended up in Laufenauer’s mental observation ward or other departments of the hospital. Apart from the mentally disturbed and suicides, we can read about thieves, cross-dressers, forgers and other criminals brought in to Laufenauer’s mental observation ward.64 The hospital was not isolated from, but rather served as the hotbed of the use of tricks, pseudonyms, deviant behaviour and imposturing. While criminals wanted to escape65 from the hospital, others tried to get in. Women “bored of honest work” and other “pseudo patients” wandered around in the country and, feigning different illnesses, sought “treatment, or rather board.”66 Under the heading “Overcrowded hospitals,” articles described the general tendency of the deprived destitute seeking hospitalisation for want of food, winter dress, a warm shelter—or their health—especially during the cold winter months.67 A concrete tragic incident also illustrates the shortcomings of the conditions and patient management system at the observation ward and may have contributed to the eventual move of the clinic from Saint Roch Hospital two years later. Sensationally introduced as a “unique case in the history” of mental institutions, the article, entitled “The Horrors of Saint Roch Hospital (The Mad Strangler)” in the popular daily Pesti Hírlap tells the story of a raging mad who murdered his fellow patient at Laufenauer’s ward in 1887. The 28-year-old attacker, Géza Beer, a merchant, was brought in the observation ward from the countryside as “dangerous to the public” two days prior to the event, and the 39-year-old married victim, János Gerstner, a grocer, was admitted the same day at Moravcsik’s

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recommendation. The two mental patients seemed to have “hit it off with each other.” That evening, they went to bed in a good mood, at night, however, the young man was overwhelmed by agitation which turned into raging. As there was nothing to break in the room, he grabbed the other man lying on the ground and with a great force, threw him to the wall. When he saw that the other was still alive, he grabbed his neck “with iron fist” and strangled him. No-one heard anything at the ward and the nurse only found the older man lying lifeless on the ground when he entered the room at 6am the next morning. The murderer was in a good mood and openly admitted his deeds to the ward doctor on duty.68 Dissection the next day proved that the older man was brutally hurt, his internal organs and bones badly bruised and broken, the attacker apparently kicked him and trampled on him many times.69 The article provided a good glimpse into the conditions prevailing at the ward. The male mental observation ward was on the second floor and comprised 9 “smaller cells” with strong iron rails on the windows, all opening to a long corridor which was separated from the rest of the hospital with a locked door. Each cell had a small window towards the corridor, so that the staff could see what the patients were doing, although it was also revealed in the article that there was no gas lighting in the rooms, only in the corridor, making visibility problematic after sunset.70 The corridor could only be entered with the permission of the ward doctor and by ringing the bell which alarmed a nurse who always stood by the door, inside. Concerning medical staff, Laufenauer led the ward, Moravcsik on his side (who had lodging in the hospital on the first floor) and with two young doctors who were on practice. In addition, only one chief and four assistant nurses cared for the patients. Five cells were equipped “according to professional needs,” these were provided for calmer patients, while 4 cells were completely empty and kept for raging mental patients who only received hay-sacks with sheet and blanket for the night.71 The ward set up for a maximum of 21 mental patients actually housed 29 that day out of necessity. The day Beer arrived, there was initially space only in one of the furnished rooms. They knew he had been already under observation three times before and had also spent time at Lipótmez˝ o asylum, and that he had raging fits. But he was calm the day when Gerstner arrived, therefore they placed him with Beer as all the other rooms were crowded. The two ended up in one of the empty cells kept for the raging.72

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The small number of nursing staff was seen as one of the main factors that contributed to the deadly incident. Five nurses for such a large group of mental patients was seen as very insufficient. In addition, no proper night shift was set. Normally, all nurses went to bed at 10 pm, one of them slept inside the corridor at the door to let newly admitted patients in if necessary, and “they sleep deeply, exhausted by the long continuous duty.” This explained why they did not notice anything from the otherwise probably noisy tragic event. Had the nurses been able to take turns at walking down the corridor and checking on the patients every two hours at night, such incidents could not have taken place, the author of the article claimed (4). It also turned out that Beer threw blankets and sheets out of his room down to the inner court. These turned out to be missing from Beer and Gerstner’s room. When the nurse asked Beer why he did it, he allegedly answered in an agitated state that because he wanted to. Then the nurse turned to Gerstner and asked why he did not report Beer’s deeds, Gerstner answered that “Beer threatened to strangle him if he dared to speak about it” (4). The nurse then failed to report this statement to the doctor on duty or to Moravcsik, although the nurses should have reported any sign of agitation immediately, day and night. This was regarded as a “nonfeasance” or gross negligence on the part of the nurse and also contributed to the death, since had it been reported, the doctor would have been required to visit the patient and order sedatives or apply strait-jacket or isolation if necessary, taking notes of his observations and decisions, the article claimed. The previous night there was no report on the patient’s condition and hence the doctors could not prevent the tragedy. The nurse would have to face gross negligence. It now seemed evident that Beer strangled his roommate as a revenge for what he had said to the nurse (4). In another daily, the chief nurse blamed the death on the nurse who slept in the corridor and who “should have known the nature of the patients but still said that the mad [Beer] was calm and harmless and could be put together with the other patient.”73 Yet another daily argued that even the move of Beer to Gerstner’s room should have been reported to the doctor but it was not, seen as another mistake made by the nursing staff.74 Another popular daily paper, Budapest Hírlap completely exonerated the doctors and blamed the tragedy on the city management: “the town council should take full responsibility for this failing, as they disregarded

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the complaints [made by the hospital management] urging the enlargement of the hospital’s observation ward every year.”75 Pesti Napló also wrote that the Board of Head Physicians (f˝oorvosi testület ) of Saint Roch Hospital held a meeting a few months prior and in April sent a detailed report to the Town Council on the state of the observation ward and disclaimed any responsibility in case of an incident in the future. After long deliberation, the Town Council eventually acted and sent experts to make local inspection and ordered the move of the observation ward to a new location which would be equipped with separate rooms for individual raging patients in the future.76 About 4–5 disturbed people were brought to the observation ward every day and a ministerial resolution ordered that all mentally ill had to be taken for observation there. Many of the patients who passed through the rather lengthy process of observation ended up at Lipótmez˝ o anyway, but the procedure to move patients there was extremely complicated and lengthy, taking two weeks and numerous reports, opinions and requests.77 In Beer’s case, who had had raging fits in the past as well and had been previously treated for months at Lipótmez˝ o, taking the mad man there directly would have probably made more sense. Daily papers also reported on the deputy Lord Mayor’s visit to the ward after the tragedy. Deputy Lord Mayor Gerlóczy immediately ordered one more nurse to the ward and promised to provide for one more intern doctor.78 In his report, Gerlóczy named the “flood of patients from the countryside” the culprit and arguing that a single ward in the capital cannot be responsible for the observation of all mental patients from the whole country, Gerlóczy recommended that observation wards should be set up at Lipótmez˝ o as well as major hospitals in the country.79 Eventually, one of the nurses was suspended from his job and the admission of new patients also stopped for a few days. It was reported that the female ward was immediately moved to another hospital to free up more space for male patients, and there were plans to eventually move the entire observation ward to a new location with more adequate conditions.80 As we know from official reports, the move only happened in 1889 but not necessarily to more adequate conditions. The move was also seen by Laufenauer as greatly problematic for a completely different reason: education.

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The Split and Move of the Clinic The greatest blow to Laufenauer’s university clinic at Saint Roch Hospital came in 1889, when the city authorities decided to move the mental observation ward to Saint John’s Hospital in Buda, in spite of Laufenauer and the Minister of Culture’s opposition.81 The small university clinic integrating the mental observation ward and nerve clinic was thus split. The mental observation ward was moved to a small house in Buda and was put under the management of the Saint John’s Hospital’s (where Laufenauer had to do doctoral service). Laufenauer held a “double” position which led to difficulties. As a professor and head of the university clinic, he was subordinated to the Ministry of Culture and Education, whereas as a chief doctor (a “city employee”), he was a part of the hospital management.82 Schaffer regarded the move of the observation ward to Saint John’s as “deportation,” complaining that the great distance and the high travel costs made it impossible for students to regularly attend.83 At the same time, the nerve clinic was transferred to the university premises on the campus of the Pest Medical Faculty (Üll˝ oi Street) where the eminent internist Frigyes Korányi offered a room with six beds for female patients and a room for histological research within his internal medicine clinic.84 The great physical distance between the university mental and nerve clinics achieved after the split also meant that Laufenauer had to travel much every day to do his duty at both clinics he headed. Even at the First National Alienist Congress in 1900, this issue elicited strong criticism from the ranks of psychiatrists. At the height of his career and influence among his fellow doctors and just a few months before his sudden early death, Laufenauer still bitterly criticised the decision and claimed that the moving inflicted considerable damage: the “transitory state” that prevailed at the mental clinic at Saint John’s Hospital for the past decade was “far more unbearable for the patients than had been the old conditions at Saint Roch Hospital.” He described the ward moved to Saint John’s Hospital as: a huge raging ward where the calmer and more reasonable patients are disturbed by the loud noise of raging patients day and night. More intelligent patients do not even have a joint common room, and there were cases when ministerial counsellor, lawyer, priest, peasant, pig-drover, cabman, journeyman, epileptic patient and idiot child, 20-21 of them all stayed in one large room! Patients are forced to receive their visitors in the midst of the noise and broil of raging patients, the gateway serves as the waiting

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room in the summer and the winter alike; the doctor’s office, where work continues for hours on end, does not even have a window, etc. In such circumstances, the building of a new observation ward living up to the standards of hygiene and humanism can no longer be procrastinated.85

By this time, the mental observation ward was enlarged to house 151 inmates. Laufenauer believed that the ward far removed from other university buildings lost its educational functions. While 60–80 students studied at the clinic in the previous semesters, after its move, the number of students fell to 30–60, he claimed in 1896.86 At the 1900 Congress, he bitterly stated that “university teaching in psychiatry is equal to zero.”87 In Laufenauer’s mind, such a split between mental pathology and nervous disorders as embodied in the physical separation of the two parts of the clinic was especially disadvantageous. He tirelessly negotiated with town authorities and the ministry for the establishment of a large separate psychiatric clinic since 1882.88 The question was discussed at the 1900 Congress. A core question was the location of the planned new institution. Instead of the Buda location of the existing ward, Laufenauer favoured an institution on the Pest side, close to the Budapest Medical Faculty on Üll˝ oi street. He argued that 86% of the admitted patients were from the Pest side, while only 14% from Buda. The majority came from districts VII, VIII, IX, X, “so even statistics point to the line of the Üll˝ oi street.” Most poor outpatients were also from the poorer Pest area; for them and their visitors, easy and cheap transportation was not possible to Buda. And finally, as Laufenauer explained, proximity to the Medical Faculty and other clinics was also in the interest of university education in general, which “completely deteriorated after the moving of the ward to Buda” in 1889.89 Jen˝ o Konrád, director of Lipótmez˝ o public asylum, and Jakab Fischer, hospital psychiatrist from Pozsony, agreed with Laufenauer on the location, while the Lipótmez˝ o chief doctor Salgó opposed him, arguing that observation clinics were mostly situated on the outskirts of towns, like in Paris, which did not hinder patient transportation. But he agreed with the aim of the patients’ quick transferral to other institutions, since the ward or clinic was “not an asylum,” and therefore “the quick change of the clinical material is important.”90 Such a significance attached to the question of location is understandable in the context of the rapid urbanisation and population growth of Budapest during the last decades of the nineteenth century. Whereas the

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population of Buda, Pest and Óbuda in 1869 was approximately 269,000 people, by 1880 Budapest had 370,000 people, in 1890 506,000 and in 1896 618,000.91 This created an increasing demand on the psychiatric ward, especially from the poor living in Pest. There were different European solutions for how a psychiatric clinic should fit into the life and anatomy of the city. Probably because of the long tradition within these institutions, important psychiatric wards set up at the Salpêtrière and Sainte Anne in Paris were on the city’s peripheries. Henry Maudsley’s own privately established hospital that, uniquely in England, was planned primarily for research and not for asylum functions, stood in South London. In Germany, according to Engstrom, three types of psychiatric clinics existed: “largely independent institutions (Halle, Kiel, Breslau, Heidelberg, Leipzig, Freiburg, Greifswald, Munich, Würzburg, Tübingen), of separate wards within urban hospital complexes (Berlin, Strassburg, Königsberg), and of wings in provincial asylums (Göttingen, Bonn, Marburg, Erlangen).”92 In Vienna, as we saw, the first 1870 clinic was set up in Riedl’s more peripheral, large mental asylum where Meynert worked, whereas the second in 1875, at the centrally located General Hospital. Therefore, even Vienna did not provide a single model concerning location and the type of mental institution such a clinic should form a part. In Budapest, the arguments centred on professional needs and on the most practical condition inseparable from any growing city: transport. The crucial issue was easy access both for students (thus necessary closeness to other Medical Faculty clinics) and patients, as well as the easy and quick transport of patients to other mental institutions. There was also a strong consideration of the conditions of poor patients. Laufenauer did not live long enough to see the new clinic opened in 1908, for which he had ardently lobbied.

Academic Research by Károly Laufenauer and Károly Schaffer Neuro-Anatomy, Neuro-Pathology and Brain-Histology The novel significance of the university clinic, however, lies in that it allowed the development of academic research in the anatomy, chemistry, and physiology of the brain and the nervous system, and thus was

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instrumental in the appropriation of the neurological sciences by psychiatry. In Hungary, psychiatric interest in brain and neural research arose from two sources. On the one hand, research on the nervous system was traditionally rooted into internal medicine. On the other hand, Hungarian psychiatrists’ interest in neuro-pathology from the 1870s was also strongly influenced by contemporary—mostly German and Austrian—psychiatric research. Throughout the nineteenth century, the study of the nervous system generally belonged to the domain of internal medicine: research on the anatomy and function of the brain and the nervous system was conducted within this field throughout Europe. In Hungary, the most eminent representatives of this trend were József Lenhossék, internationally reputed professor of the nervous system and head of the Hungarian Anatomy Institute (son of the Mihály Lenhossék, eminent physiologist of the first part of the century), and Frigyes Korányi influential internist and head of the Department of Internal Medicine at the Budapest Medical Faculty. (It is telling that the first microscope ordered from Paris by the Association for Natural Sciences in 1843 was given to Mihály Lenhossék who held microscopic demonstrations at the Association on every Saturday.) Laufenauer’s young colleague, Károly Schaffer, who became the most eminent Hungarian neuro-anatomist and neurologist with an international reputation by the turn of the century, first learned brain anatomy and the structure of the nervous system from Lenhossék during his university studies. Upon completion, he immediately began to work at Laufenauer’s mental and nervous clinic. Neuro-pathological research and neurological practice were closely intertwined with internal medicine in the minds of many. Even by the turn of the century, some of the neurologists who performed psychiatric clinical practice identified themselves primarily as internists. The best example is the psychiatrist—internist Ern˝ o Jendrássik (1858–1921), head of the first Neurology Department set up at the Budapest Medical Faculty in 1893. Jendrássik stated in his inaugural speech at the opening of a new nerve clinic he was appointed to head in 1902 that “neuropathology [must be] cultivated within the larger framework of internal medicine,”93 since “no other field is as closely tied to its mother field as neuro-pathology, for nervous diseases derive from the same sources as internal diseases.” But his understanding of the nature of nervous disorders also supported this close connection: “the altered functioning of the nerves together with the original cause bring about further changes. How

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would it be possible to judge the fate of the patient if the observer did not equally know nervous as well as other internal diseases?”94 Psychiatrists’ move into the area of neuro-anatomical and physiological research was in a way the appropriation of the subject through research and publication, but also with institutional means, namely with the establishment of the university clinic (followed by several wards at hospitals) integrating nervous and mental pathology. Although by the first decades of the twentieth century, internal medicine textbooks still included the structure, function and disturbances of the nervous system, many of these chapters were written by psychiatrists/neurologists, like Laufenauer and Jendrássik.95 Next to internal medicine, the other influence was contemporary Western mental pathology.96 From the 1860s and especially the 1870s, many young Hungarian doctors who later became prominent psychiatrists visited Western centres of research after acquiring their diploma at the Budapest or Viennese Medical Faculties. During these decades, more energetic publication in the field (including the translation of influential foreign books and articles) also made Hungarian psychiatry more immediately receptive of new Western research. As Moravcsik reminisced, due to this new interest in neuro-scientific research from the 1870s, “mental pathology clinics transformed into laboratories of the healthy and pathological anatomy and histology of the central nervous system.”97 The influence of German-language psychiatric research was remarkable in this respect.98 The Viennese Meynert’s influence was the most considerable in starting neuro-pathological research (Laufenauer, Schaffer, Jendrássik and Donáth all studied with him for shorter or longer periods), but Westphal, Wernicke, Ebbinghaus and other excellent representatives of the anatomical and experimental psycho-physiological investigation also became highly influential in Hungary.99 Laufenauer’s own neuro-pathological research began in the second part of the 1870s. As discussed in Chapter 7, Niedermann’s 1865 article in Orvosi Hetilap was one of the first publications I found that explicitly elaborated on paralysis progressiva. Niedermann believed that “the development of science to the direction of objectivity which penetrated this disease” was made possible with the appearance of massive number of patients on the dissection table,100 a considerable portion of which was deceased paralytics. Related Hungarian research, however, did not start until the 1870s, and then it was initiated by Laufenauer (Niedermann’s publication was only a review article).

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As a young graduate, Laufenauer studied a year (1875–1876) with Meynert in Vienna and Westphal in Berlin. Taking back his interest and enthusiasm in neuro-pathology and physiology, in the following three years at Lipótmez˝ o, he dissected the brains of numerous patients who died at the asylum and conducted histological research. He gave his first presentation on paralysis at the Royal Society of Budapest Physicians on 1 May 1877 and published it in Orvosi Hetilap (Medical Weekly) in 1878.101 The case was of a patient who died at Meynert’s clinic while Laufenauer was there. On 8 May 1878, Laufenauer’s privatdozent lecture was on the clinical picture, aetiology, and pathological anatomy of paralysis he also published. He enthusiastically claimed that: “the shibboleth of the epoch-making new trend in the history of psychiatry is: search the pathological object, the brain itself, and observe its macroscopic and microscopic composition; weight; pathological chemistry; and physiological and pathological functioning.”102 He studied and greatly contributed to the pathological histology of nerve-lesions in the brain, the cerebellum, the medulla and the spinal cord103 ; the neuro-pathology of epileptic mental disorders, chorea gravis, catatonia,104 etc. In order to demonstrate the value of neuro-pathological and histological research, Laufenauer made use even of his own faulty diagnosis. In an article on secondary paralysis in 1882, he presented a case where he was forced to re-evaluate his own mistaken diagnosis of a patient in the light of the dissection conducted after the patient’s death. “Two mistaken diagnoses corrected by the results of the post-mortem are much more valuable in clarifying the question than a whole volume of casuistics which, without the confirming results of post-mortem dissection, hardly prove anything at all.”105 Patho-anatomical research and the neurological treatment of patients were combined at Laufenauer’s university clinic as well as subsequently in other mental and nervous observation wards in Hungary. His mental ward became the first centre where neuro-pathological research and clinical practice were combined in the country. After the split and transfer of the department in 1889, the nerve clinic on the medical premises consisted of an ambulantorium for outpatients (whose number greatly increased during the years) in a small dark hall and a lighter room looking on the street; a six-bed “klinikoid”106 whose patients were supplied from the ambulantorium; and a laboratory. The ambulantorium was run from 9 to 12 in the morning; Schaffer and other young doctors continued with histological research from the early afternoon till the evening.107

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Laboratory work, outpatient neurological practice and the clinical observation and treatment were thus closely connected and confined within the small nerve clinic. Several young neurologists received their training and began their career at the clinic: Artúr Sarbó (1867–1943) later eminent neuro-pathologist, Kálmán Pándy (1868–1945), who discovered the liquor-reaction named after him, Pál Ranschburg (1870–1945), later famous psychologist and one of the first representatives of experimental psychology, Károly Hudovernig, and Ödön Németh. The most talented and successful Laufenauer student, however, was undoubtedly Károly Schaffer. While he later had an extensive neurological practice, Schaffer embodied a new type of researcher with his primary preoccupation in focused study: he conducted brain-histological research at the clinic, and prepared fine excisions which he tirelessly studied under microscope. Schaffer’s biographical details and work amply demonstrates the nature of neuro-pathological research and the rise of the modern neuro-scientist. Károly Schaffer’s grandfather was born in Kolozsvár (Transylvania) and later moved to Vienna with the family. Károly’s father was a sculptor who studied at the Viennese Academy and moved to Pest with his son in 1865. Perhaps thanks to his artist father, Schaffer was talented in drawing, he was attracted to lines since his childhood, something that he could make good use of later when he produced thousands of drawings on the nervous system. When, at the age of 12, he first peeked into a microscope at school and caught sight of the colourful and circularly layered starch particles on the potato-scrape on a glass-plate, he allegedly exclaimed with enchantment “I could spend my entire life by a microscope.”108 This wishful anticipation undoubtedly came true. Schaffer studied anatomy with József Lenhossék (eminent professor of the nervous system, mentioned above) who also employed him as a paid demonstrator at the Anatomy Institute. Schaffer became very good friends with his teacher’s son, Mihály Lenhossék (1863–1937) (who became an internationally reputed nerve-morphologist and histologist, and with Schaffer, the Hungarian representative of the “neuron-theory” of the Spanish Nobel Laureate Santiago Ramón y Cajal109 ); the young men together studied the structure of the nervous system from the fine excisions closed between glass-plates, prepared with a razor by József Lenhossék. Schaffer got some of these excisions and kept them as relics, and later he prepared his own myelencephalon excisions (that he donated to the Viennese Neurological Institute). He also compared the human

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cerebrum with that of kittens under the microscope.110 Two other young scholars who formed a scholarly circle of neurologists around Schaffer were another Lenhossék student: Ferenc Tangl (1866–1917), and Frigyes Korányi’s son: Sándor Korányi (1866–1944). Unlike Schaffer, these two stayed within the disciplinary boundaries of internal medicine. Schaffer had the chance to attend some of Meynert’s lectures on mental and nervous pathology and the diseases of the forebrain in Vienna during his university years. In the third year, he went to Laufenauer’s lectures in Budapest on the healthy and pathological histology of the nervous system which absolutely fascinated him. Schaffer’s first scholarly publication in his fourth year was the result of his own independent research on the lesion of the medulla spinalis due to rabies published in the Orvosi Hetilap (Medical Weekly) in 1887, entitled Adatok a veszettség kórszövettanához (Data Concerning the Pathological Histology of Rabies, which was also published in the Archiv für Psychiatrie). In 1887–1890, Schaffer published further articles on the pathological histology of rabies. The results of this research by Schaffer was presented at the Academy in 1889 by Endre H˝ ogyes, an eminent Hungarian expert in the field, as well as published in German in distinguished journals. (H˝ ogyes was already involved in researching the vaccination against rabies as a result of which he refined Pasteur’s technique and came up with a cheap and efficient form of vaccination that later became widely used in most countries). Schaffer was Laufenauer’s right hand at both the six-bed female neurology ward as well as the histology laboratory of the clinic. In the latter, he continuously introduced and used the latest observation techniques and impressed Laufenauer with his excisions prepared with Weigert’s and then Nissl’s painting technique, then with Ramón y Cajal’s silvering method or Marchi’s osmium method (41, 46–47). In the early 1890s, he widely published in the field of pathological histology of the brain and the spinal marrow, on paralysis progressiva, tabes dorsalis, etc. in Magyar Orvosi Archivum (Hungarian Medical Archives), Természettudományi Közlöny (Natural Scientific News), Orvosi Hetilap (Medical Weekly) and Budapesti Orvosi Újság (Budapest Medical Journal). Also at the clinic, he became involved in the lively hysteria and hypnosis research begun by Laufenauer and H˝ ogyes in 1883. Through 1892, Schaffer studied with them physiological and reflex phenomena under hypnosis and wrote a book on hypnotism in 1895. During his trips abroad, Schaffer visited Weigert and Edinger in Frankfurt in 1890. Schaffer impressed Weigert with his histological samples

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prepared with Weigert’s method, and with the fact that, during the dissection of the myelon of a patient who died of tabes, Schaffer recognised the lesions in the back fascicule with his naked eye. He became a good friend of Edinger (49–50) expert of the fibre-structure of the nervous system and comparative anatomy. In 1894, he visited Hippolyte Bernheim in Nancy and discussed with him current questions related to hypnosis. He also visited the neurologist Fulgence Raymond (Charcot’s successor at Salpêtrière), Valentin Magnan’s ward at Sainte Anne in Paris and August Forel at the Burghölzli in Zurich (40–50). At the age of 28, in 1893, Schaffer became privatdozent of neuropathology and neurology at the Budapest Medical Faculty, and two years later he left the nerve clinic to continue as a doctor at the mental (160 beds) and nervous diseases (50-beds) ward of Elizabeth Poorhouse Hospital in Budapest (today Korányi Hospital), as well as took up the neuro-pathologist’s position at the Count Albert Apponyi’s Polyclinic in Szövetség Street. Since both positions were unpaid, he supported his family with private medical practice (40–50). In these places, he studied inherited diseases of the central nervous system through combining clinical111 and histological practices: studying living patients and then dissecting them after their death (which was very frequent in these hospitals). At the Elisabeth Poorhouse Hospital, he also set up a small histological laboratory at his own expense (with very little support from the University) and worked with his young volunteer colleagues: Artúr Sarbó, László Epstein, Rezs˝ o Bálint, Sándor Ferenczi, Ern˝ o Frey, László Balassa and Pál Ranschburg. The psychoanalyst Ferenczi and experimental psychologist Ranschburg learned basic brain structure and brain pathology and acquired basic neurological knowledge from Schaffer, and Sarbó studied syphilitic nervous diseases and sclerosis multiplex.112 His laboratory work was not financially well-supported, and he had to invest into the histological laboratory at the Poorhouse Hospital. When Schaffer was asked to exhibit at the 1899 Paris World Exhibition, the state granted him 900 forints which greatly improved the laboratory’s poor conditions. Schaffer bought a huge brain-cutter and a machine that could take micro-photographs which enabled him and his assistant, Frey to produce and observe thousands of brain cuttings covering the entire brain. Schaffer’s brain-cuts brought him a silver medal at the exhibition.113 The hospital supplied Schaffer with a very rich source of patients: hundreds of patients who died of some organic nervous disease. Apart

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from numerous articles, Schaffer published his neurological findings in his book Anatomisch-Klinische Vorträge aus dem Gebiete der Nervenpathologie (G. Fischer, Jena) in 1901, introduced with the highly supporting words of the great German internist-neurologist Adolf Strümpell. Schaffer has been neglected as a scientist who was greatly influential as a neuro-histologist and was the founder of a school of psychopathology with many famous Hungarian students, including Dezs˝ o Miskolczy, Kálmán Sántha, István Könnyei and László Meduna, inventor of convulsive therapy. He thus put Budapest on the map of excellent psychiatric research centres, including Berlin, Frankfurt, Munich and Vienna. His findings in neuroanatomy include the definition of the neuron and the demonstration that it was an independent unit which was contiguously connected to other cells thus forming the central nervous system in 1904114 (this was the theory of contiguity, as opposed to the theory of continuity, which assumed that the cells were continuously connected; the former was professed by Ramón y Cajal and József Lenhossék in Hungary, the latter by István Apáthy).115 He also greatly contributed to the histological understanding of TaySachs disease, for which it is often called Tay-Sachs-Schaffer disease. It is a rare inherited disorder that has a debilitating effect by progressively destroying nerve cells in the brain and the spinal cord. Most usually it begins in infancy and becomes manifest in the weakening of the muscles used for movement as well as vision and hearing loss, children often die within a few years. Aspects of the disease was already described by British ophthalmologist Waren Tay and American neurologist Bernard Sachs in the 1880s, but it was Schaffer who gave a full histopathological description of it after years of enquiries which began with the post-mortem dissection of infants who died of Tay-Sachs disease at the Adél Bródy Israelite Children’s Hospital.116 (It was soon noted that Ashkenazi Jews had a high incidence of Tay-Sachs disease, which was especially relevant in the Hungarian case, given the high number of Ashkenazi Jewish migrants arriving from the Russian Empire at the time). Hypnosis Studies In addition to the research practices discussed so far (brain dissection, histological laboratory work and microscopic observation), there was another type of research that became emblematic of the psychiatric clinic (and neurological clinics more generally): experimental study of hypnosis

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in the 1880s–1890s.117 Since hypnosis had been traditionally strongly linked to the dubious dealings of questionable practitioners beyond the boundaries of respectable science, it seems to be an odd choice for professionals of academic and clinical psychiatry. Yet evidence suggests that hypnosis became central to university clinical studies and that its investigation served clear professional and academic goals. Hypnosis research reveals professional anxieties over the “scientific” underpinnings of psychiatry in the period when the profession was still struggling to gain credibility and status among the medical disciplines. Hypnosis studies or the experimentalization of hypnosis thus partly aimed at strengthening psychiatry as a science. The first hypnosis experiments at the psychiatric clinic focused on physiological phenomena and were conducted by Laufenauer and the eminent experimental pathologist, physiologist and bacteriologist (hailed later in his country as the “Hungarian Pasteur”) Endre H˝ ogyes (1847– 1906). The three patients used in the experiments were all suffering from hystero-epilepsy (a severe form of hysteria with epileptic-type seizures). Once the experimental trials at the clinic were deemed mature, the doctors presented their findings in front of learned audience at the Academy of Sciences and the Royal Society of Budapest Physicians in 1884.118 Admittedly following Charcot and his French colleagues’ line of research, the Hungarian doctors claimed innovation on two fronts. First, they stated that they considerably extended the French experiments and “found new phenomena” related to the visual, auditory, olfactory and gustatory nerves, the proper stimulation of which resulted in specific reflex-movements in the patients. Second, they claimed to have “discovered” that these phenomena were reproducible in the patients’ lucid, normal state as well and therefore were primarily due not to hypnosis but to the pathological conditions related to hystero-epilepsy.119 In complex experiments, the stimulation of the skin- and tendonreflexes and the visual, auditory, olfactory and gustatory nerves produced different patterns of contractions of different muscle groups of the upper and lower body. At the end of his presentation, H˝ ogyes claimed that, from these experiments with involuntary reflex-contractions, where not only the distinct sensory reflex functions were minutely studied but also their intricate inter-relationships, “a universal law of nerve-physiology can be concluded” (ital. mine), which he named “the unity of sensation in movement.”120

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In the following eight years, H˝ ogyes continued the research, but, since he was already involved in research on a vaccination against rabies,121 he heavily relied on Laufenauer’s young and ambitious student, Károly Schaffer. H˝ ogyes and Schaffer’s hypnosis research culminated in significant lectures at the Academy, the Association for Natural Sciences, and the Royal Society in 1892.122 Schaffer then published his extensive experiments and theory in a long scholarly paper in 1897 and the first Hungarian book on hypnosis in 1894–1895 (also published in German in 1895).123 The majority of the presented phenomena were similar to the above-described 1884 experiments, with some modifications. The new elements in 1892 were the successful use of verbal suggestion instead of physical stimulation in producing the same reflex phenomena, and the use of “negative suggestions.”124 It seems that doctors followed clear strategies during their experimentation. First, the careful choice of the object of the experiments was crucial in the establishment of hypnosis as a reliable technique that could not easily be contested. To this end, the doctors largely confined their studies to physiological and reflex phenomena and refrained from more controversial, “behavioural” experiments (which abounded in later demonstrations at other clinics and eventually undermined the reliability of those studies, see below). They successfully presented some of the experiments also without hypnosis, in the normal lucid state, in order to demonstrate that hypnosis was not only a reliable technique that produced phenomena also observable in the normal state, but one that offered an insight into the functioning of the nervous system better than any other technique. One that functioned as a kind of amplifier, since it provided an enhanced, dramatised version of those phenomena thus making them more observable. In their experimental setting, they turned hypnosis into a tool very similar to the microscope. This line of research established hypnosis as a reliable technique in the experimental setting and the physiological phenomena as the object of study.125 In addition, the doctors turned the hypnotised patient into a machine: a reliable experimental instrument that was lacking the basic human propensity of free will. In 1884, Laufenauer claimed that the hypnotised person was a “real automaton,” where the controlling force of the mind was entirely missing.126 This experimental instrument was capable of demonstrating and amplifying physiological phenomena, without failure and in the rule-like manner that is expected from a

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machine. In Schaffer’s words, “the hypnotised person gives the impression of being a reflex-machine.”127 An important second line of research emerged at Ern˝ o Jendrássik’s ward at the Second Clinic of Internal Medicine of the Budapest Medical Faculty, just a few streets away from Laufenauer’s psychiatric clinic between 1887 and 1892. Son of a highly influential Hungarian internist and physiologist, the young and ambitious Jendrássik128 (1858– 1921) spent months with Meynert in Vienna in 1884 and Charcot at the Salpêtrière in 1885 with a reward-fellowship for his studies on reflexes.129 His great interest in hypnosis stemmed from this visit to Charcot. Jendrássik also began his own investigations at the internal clinic and had his two most notable presentations before the Royal Society of Budapest Physicians in 1887 and 1892.130 Jendrássik staged experiments similar to the physiological transfer phenomena in H˝ ogyes, Laufenauer and Schaffer’s research, but in a much more complicated form and with evidently different goals. As the experiments demonstrate, he redefined the object of his investigation by shifting the focus from the physiological phenomena to the power of suggestion. His goal thus became probing the limits of hypnosis itself. These experiments related to behavioural phenomena and more explicitly focused on the free will and its forensic consequences. For instance, the patient was told under hypnosis that she was a dog, and thus she went down on all fours and barked. In another experiment, he suggested that she murder one of her doctors, and thus she stole behind him and tried to stab him with a roll of paper given to her.131 Under hypnosis, she was asked to write love-letters to a doctor who, as she was told, murdered her father. She wrote it without hesitation.132 Serious controversies arose after Jendrássik’s presentations over issues of scientific objectivity, reliability of the technique of hypnosis, questions of proof, the problem of replication in the experimental setting, as well as medico-ethical concerns around psychiatric practice. There is no space here to discuss all of these in depth, but they nevertheless prove what were at stake during this experimentalisation of hypnosis: the very attempt to prove psychiatry’s scientific credentials and capacities while also providing insights into mechanisms of the brain and the mind. By the end of the 1880s, the usefulness and potential harms of hypnosis were widely discussed in Hungary as well as in international psychiatric forums.133 While the medical establishment unanimously repudiated its lay practice, many doctors emphasised that it had great therapeutic values

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and was harmless in an expert’s hands. There was, however, no consent as to the general scientific and therapeutic use of hypnosis. While many nerve-doctors widely used hypnosis as a therapeutic means in their neurological practice and academic psychiatrists saw it as a great research tool, hefty dissent came from the ranks of mental asylum doctors. This dissent was representative of a more general and deep schism that emerged within psychiatry by the end of the century, a schism that can be explained by the crucial differences between forms of life, theories of mental illness and practices embodied in the institutions of the asylum and the psychiatric clinic, respectively. The debates and publications in scholarly forums following the experiments prove that while asylum doctors suggested a general refrainment from hypnosis in case of mental and nervous patients, practitioners at clinics held different views on these disorders and shared different attitudes towards therapy and research. In an article in Medicine in 1889, Ödön Blum, doctor at Angyalföld public asylum stated that he had conducted (mostly therapeutic) hypnosis in more than 100 cases and found neuropathic patients susceptible to hypnosis, whereas mental patients were hardly hypnotisable at all.134 This view was more widely held,135 and certainly was one of the reasons why asylum doctors were much more reluctant to use hypnosis than nerve-doctors. Yet Blum stressed that it could elicit epileptic fits in predisposed persons, and that it increased excitement both under and after the session. “Thus, it often has a detrimental influence on the nervous system – on the already excitable nervous system.” This added to the patient’s already existing problems, the lack of hunger, headaches, increased heartbeats and great restlessness. Blum concluded that “due to the little success with hypnosis compared to the dangers that increased nervousness,” its use should have been greatly curtailed.136 Another fierce attack came from the eminent Lipótmez˝ o public asylum chief doctor Jakab Salgó (also the author of an influential mental pathology textbook). In a long article in Clinical Papers, Salgó stated that hypnosis both presupposed and negatively affected a disturbed and unbalanced nervous system whose further excitation was greatly detrimental to the patient, with hypnosis the doctor only aggravated the patient’s condition.137 His criticism therefore targeted the question of the doctor’s traditional role and function of healing. Salgó also argued that hypnosis should not be experimented with even for therapeutic purposes, as.

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the human being is perhaps a too precious experimental animal for the study and understanding of a pathological state. (...) Hypnotic experiments and treatments are not so important for science so that we should reduce human beings to the value of experimental animals.138

Instead of using artificial hypnotic suggestions in treating nervous patients, Salgó advocated the age-old practice of the doctor exerting his positive and curing psychic influence on the patient, a therapeutic tool he called the “traitement moral,”139 a term originally coined by Pinel at the Salpêtrière in 1801 and designating a concept and practice that had shaped asylum life in many European countries in the subsequent century. From the experiments, as we saw, striking images of the hypnotised person emerge in the forms of the “dissected frog,” the “reflex machine” and the “simulator,” which reflect problematic perceptions of the patient. Many of the research practices at the psychiatric clinic discussed earlier in the chapter showed an interest in the “dead” rather than the living patient, and in the case of living patients, the primacy of experimentation over treatment. Such experimentation reflected the sacrifice of the unity of the mind, soul and body of the person. Thus, in addition to professional power struggles, asylum doctors’ fierce attacks on laboratory research were also an attempt to rehabilitate the living patient and the holistic view that had traditionally characterised asylum psychiatry. Triggered by a fatal hypnotic séance in the far outstretch of the Kingdom and the intense international media coverage it received,140 the Hungarian Ministry of Interior—at the recommendation of the National Public Health Council —passed a resolution in 1894 that greatly limited the practice of hypnosis in the country.141 It prohibited anyone unqualified for medical practice from using it and strictly defined the circumstances under which even doctors could employ hypnosis. Strikingly, in a crucial decision unprecedented in Europe, it allowed for the medical use of hypnosis only with the aim of a cure. This prohibited not merely staged demonstrations but also academic research experiments in hypnosis. The legislation thus seems to have been both a response to growing concerns over spiritualist séances thriving in the country and an indication of the professional disagreement over the dangers perceived in medical hypnosis. Several doctors with neurological practice welcomed the resolution, which banned hypnosis by “charlatans” for “spectacular events,” but complained that the resolution “tied the hands of the researcher doctor” while at the same time “hypnosis was thriving in the

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country at secret meetings,” hypnotists with ill-reputation still carried on their “trade” as if there had been no such prohibition.142 Schaffer urged a further resolution that would regulate the conditions within which academic research on hypnosis could continue in the future.143 But no such resolution followed. Hypnosis remained a therapeutic tool used by some doctors in the 1890s and beyond, but suggestive therapy—where no hypnotic state was induced to achieve the therapeutic goals—took over hypnosis and became one of the most significant tools to treat nervous patients in the new century and then shell-shock patients during and after World War One, as we will see in Chapter 8.

The Integrative Function of the University Clinic in a Fragmenting Profession To return to the department of mental health and pathology and its clinics, Laufenauer’s role in this phase of the history of Hungarian psychiatry was crucial. His extensive knowledge and varied experience in different types of institutions made him open to new approaches. Shortly before his death, he supported Pál Ranschburg (1870–1945), one of the first Hungarian representatives of experimental psychology, in setting up a Wundtian laboratory at the university clinic in 1899.144 After Laufenauer’s death in 1901, however, the position of Ranschburg and his “psycho-physiological” laboratory raised conflicts and hostility among members of the Budapest Medical Faculty, and thus the laboratory was moved to an institution for mentally disabled children in the Mosonyi Street in 1902.145 In line with Laufenauer’s approach, Ranschburg combined experimental —psychology with experimental and clinical neurological research. After the sudden death of Laufenauer, his position as head of the department had to be filled. Schaffer and Moravcsik were the only possible candidates. While both studied under Laufenauer, who professed the importance of the connectedness of mental and nervous pathology, and both had clinical practice with mental and nervous patients, they had fundamentally different orientation. Moravcsik—more interested in the clinical trend in mental pathology and forensic psychiatry—became one of the most eminent clinicians at the turn of the century, praised as the master of fine psychiatric observations who also did not neglect neuro-pathology. At the same time, Schaffer represented the neurological direction and founded the first distinct neurological school in the country.

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Against the Medical Faculty’s unitary nomination of Moravcsik, only Mihály Lenhossék supported Schaffer, while admitting Moravcsik’s merits. He saw greater promise of scholarly-academic productivity and international influence in Schaffer’s person (which was certainly a justified claim: Schaffer published widely in foreign languages and had remarkable connections with outstanding foreign experts, while Moravcsik’s reputation was more confined within the borders of Hungary). Lenhossék also regarded Schaffer as the representative of both the clinical approach to mental and nervous pathologies and of modern histological and anatomical knowledge, whereas he regarded Moravcsik more the representative of an older type of psychiatric clinical observation.146 The Budapest Medical Faculty elected Moravcsik as the head of the university clinic. This choice thus placed less emphasis on neuro-scientific research and more on clinical work, but nevertheless meant continuing the Laufenauer-line: integrating mental and nervous pathology. Laufenauer’s ideal of an integrated approach was further strengthened in 1908 with the opening of the large, separate, modern University Clinic of Mental and Neuro-pathology on Balassa Street,147 close to the other university clinics. The new clinic built in the modern pavilion system was considerably larger than the previous one, which made the longterm observation and treatment of a large number of mental and nervous patients possible. The clinic housed 160 patients, and 180–220 students studied there every semester which shows an incredible increase compared to the situation of psychiatric teaching at the old clinic. Furthermore, it was equipped with modern laboratories for neurological research.148 Ern˝ o Moravcsik was Kraepelin’s most prominent Hungarian follower, and the clinical trend he represented “rehabilitated” the patient by pursuing a more holistic view. He reformed patient observation and produced lengthy case studies, with the description of the patient’s condition at the time of admission ranging from between 10 and 30 pages, and the report on the course of disease often exceeding 60 pages and including the detailed account of dreams, doctor-patient dialogues, association-experiments with reaction times, etc.149 At the clinic, Moravcsik used methods of experimental psychology,150 and supported the first representatives of psychoanalysis at a time when other psychiatric circles despised the new movement. Jendrássik, for instance, like a number of other conservative and prestigious professors, vehemently refused psychoanalysis and was consistently hostile till the end of his life towards its Hungarian representative, Sándor

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Ferenczi (1873–1933). At the end of the chapter on hysteria in the 1914 Textbook of Internal Medicine, Jendrássik refers to sexology and psychoanalysis as “pornography in disguise” and claims that treatment which consists of the “molestation of the patient with the most indecent questions in private interrogation (…) is a real menace to young women.”151 Jendrássik had a direct influence on Ferenczi’s career, and thus indirectly on the history of psychoanalysis in Hungary. Following their unsuccessful demands in 1918–1919 winter that Ferenczi (who was not yet a Privatdozent) give lectures on psychoanalysis at the university, students wrote a letter to the Minister of Education requiring regular lectures on psychoanalysis. To provide information on the question at the request of the Ministry, the Dean asked Jendrássik to write a report. Jendrássik rejected the idea of Ferenczi’s appointment as Privatdozent and claimed that the “false doctrine” of psychoanalysis is not taught at foreign universities, and the greatest scholars (giving a long and illustrious list of foreign professors) reject the “pornography and interpretation of dreams” calling itself psychoanalysis.152 Though paradigmatic for leading neurologist circles, Jendrássik’s attitude was not the only possible one. At a time when Freud’s name was uttered only with contempt and psychoanalysis received harsh criticism, Moravcsik claimed in his 1913 book Az idegbetegségek gyógyítása (The Cure of Nervous Disorders) (Budapest: Franklin) that Freud’s method offered a glimpse into the mysterious mechanisms of the psyche and represented a new direction of scientific research. A few young psychiatrists deeply influenced by psychoanalysis—such as Lilly Hajdu (1891–1960) and the writer Géza Csáth (1887–1919) started their career at the ward of Moravcsik. And it was Moravcsik himself who suggested to Ferenczi in 1918 that he apply for the position of a Privatdozent with his official support (this time Ferenczi failed to be appointed, but he got the first psychoanalytical chair in the world with the establishment of the short-lived Department and Clinic of Psychoanalysis at the Medical Faculty during the Soviet Republic in 1919).153 The new university clinic thus served an integrative function in a period of fragmenting psychiatric practice. Concerning Schaffer, in 1912 he was appointed extraordinary professor and was given a small department: the Institute of Brain Histology.154 In 1919, he became full professor of psychopathology and neuro-pathology. After Moravcsik’s death in 1924, he eventually accepted the professorship of psychiatry but only under the condition that his Institute of Brain

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Histology be integrated into the clinic and a new assistant professor position be created there. This meant yet another shift in the balance within the university department and clinics’ focus: an even fuller incorporation of neurology in Hungarian psychiatry that prevailed under Schaffer’s direction.

Notes 1. For Jen˝ o Pólya’s arguments, see Chapter 3. See József Pólya, Tudnivalók a Pesten felállított privát Elmekórintézetr˝ol (Information on the Private Mental Asylum Opened in Pest) (Pest: Házinyomda, 1842), 1–2. 2. Ferencz Schwartzer, A lelki betegségek általános kór- és gyógytana, törvényszéki lélektannal (The General Pathology and Treatment of Disorders of the Soul, with Forensic Psychology) (Budapest, 1858). 3. Ferencz Schwartzer, “Bestimmung der Irrenstalten zum psychiatrischen Unterrichte,” Zeitschrift für Natur und Heilkunde in Ungarn 10 (1854), 73. 4. Károly Laufenauer, “Néhány szó a hazai elmekórtani oktatás tárgyában” (A Few Words on Teaching Mental Pathology in Hungary), Orvosi Hetilap (Medical Weekly) 45 (1876), 90. 5. Ern˝ o Moravcsik, “A psychiatria fejl˝ odése hazánkban az utolsó 50 év alatt” (The Development of Psychiatry in Our Country During the Last 50 Years), Orvosi Hetilap (Medical Weekly) 1 (1906a), 38. 6. Jakab Salgó, Az elmekórtan tankönyve (Textbook of Mental Pathology) (Budapest: Franklin Társulat, 1890), 1–2. 7. Károly Schaffer, “Az elme- és idegkórtannak egymáshoz való viszonya és fejl˝ odése. A constitutio fogalma” (The Relationship of Mental- and Nervous Pathology, and Their Development. The Concept of Constitution) Orvosi Hetilap (Medical Weekly) 7 (1925), 135. 8. Schaffer (1935), 135. 9. See Laufenauer’s response to Jakab Salgó’s presentation in Jakab Salgó, “Az elmegyógyászat oktatásáról” (On Teaching Mental Pathology), in Az 1900. évi október 28–29-én Budapesten tartott Els˝o Országos Elmeorvosi Értekezlet munkálatai (Proceedings of

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the First National Alienist Congress, Held in Budapest, on 28– 29 October 1900), ed. László Epstein (Budapest: Pallas, 1901), 86–87. 10. Moravcsik (1906a), 38. 11. See discussed in detail in Chapter 2. 12. To avoid confusion over designations, I clarify now that the modern university psychiatric clinic was opened only in 1908 in a splendid new building, however, it was preceded with different institutions as its predecessors. As I discuss below, the attachment of a clinic to the department was crucial to provide patient material for research and teaching, this university clinic was identical from 1882 with the mental observation ward at Saint Roch Hospital; in 1884 this mental observation ward was enlarged by a small nerve clinic together forming the university clinic; in 1889 it was split into two and moved: the mental clinic to the Saint John’s Hospital, and the nerve clinic to the Department of Internal Medicine on the “medical premises.” The two parts of the clinic were finally reintegrated in the new psychiatric clinic of 1908. The predecessor institutions had different designations, to avoid confusion, before 1884, I will mostly refer to it as mental observation ward or mental clinic, between 1884 and 1887, we can speak about a joint mental and nerve clinic, after the split in 1887, physically separated mental clinic and nerve clinic. 13. See Tibor Gy˝ ori Nádudvari, Az Orvostudományi Kar története, 1770–1935 (The History of the Medical Faculty, 1770–1935) (Budapest: Egyetemi Nyomda, 1936); Béla Kollarits, István Joó and Géza Bajza, eds., Magyarország gyógyintézeteinek évkönyve, 1934 (Yearbook of Hungary’s Hospitals, 1934) (Budapest: Pápai Ern˝ o Nyomda, 1935). 14. See Chapter 2. Also see the chapter “Scientific Medicine in the Nineteenth Century” in Roy Porter, The Greatest Benefit to Mankind. A Medical History of Humanity from Antiquity to the Present (London: HarperCollins, 1997), 304–348; and William F. Bynum, Science and the Practice of Medicine in the Nineteenth Century (Cambridge: Cambridge University Press, 1994). 15. See discussed in Chapter 3. 16. See the chapter “Scientific Medicine in the Nineteenth Century” in Porter (1997), 304–348; and Bynum (1994).

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17. See also discussed in Chapter 3. See Erna Lesky, The Vienna Medical School of the 19th Century, trans. L. Williams and I.S. Levij (Baltimore and London: Johns Hopkins University Press, 1976), 96–105, 1–248. 18. Lesky (1976), 113–114. 19. Rokitanski quoted in Lesky (1976), 107. 20. Porter (1997), 315. 21. Ibid.; Lesky (1976), 109. 22. Lesky (1976), 108. 23. Ibid., 111–112. 24. Porter (1997), 330–333. 25. Lesky (1976), 112. 26. Ibid., 108, 117–119. 27. On Griesinger and Westphal, see Eric J. Engstrom, Clinical Psychiatry in Imperial Germany. A History of Psychiatric Practice (Ithaca: Cornell University Press, 2003), 51–87; Otto Marx, “Wilhelm Griesinger and the History of Psychiatry: A Reassessment,” Bulletin of the History of Medicine 46 (1972), 519–544. 28. Lesky (1976), 156–157. 29. On Leidesdorf and Meynert, see Lesky (1976), 156–160, 334– 341; Otto Marx, “Nineteenth Century Medical Psychology. Theoretical Problems in the Work of Griesinger, Meynert and Wernicke,” Isis 61 (1970), 355–370; Edward Shorter, A History of Psychiatry. From the Era of the Asylum to the Age of Prozac (New York and Toronto: John Wiley and Sons, 1997), 76–81. 30. See Marx (1970), 355–370; Shorter (1997), 76–81. 31. For Germany, see Engstrom (2003); for Vienna, Lesky (1976), 156–160, 334–341. 32. See Engstrom (2003); Shorter (1976), 76–81. 33. Engstrom (2003), 1–4. 34. See Chapter 2. 35. Lesky (1976), 158–159. 36. See below. 37. Lesky (1976), 334–335. 38. Károly Schaffer, “Laufenauer Károly jelent˝ osége” (The Importance of Károly Laufenauer), Orvosi Hetilap (Medical Weekly) 9 (1928), 244. 39. See Schaffer (1928), 244. Moravcsik regards Laufenauer’s appointment and the establishment of the department as

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the foundation of scientific research in Hungarian psychiatry. Moravcsik (1906a), 40. 40. For Laufenauer, see the memorial speeches: Ern˝ o Moravcsik, “Emlékbeszéd Laufenauer Károly felett” (Remembering Károly Laufenauer) Orvosi Hetilap (Medical Weekly) 4 (1906b), 82–95; Schaffer (1928), 243–247; Károly Kétly, Emlékbeszéd Laufenauer Károly levelez˝o tag felett (Obituary of Corresponding Member Károly Laufenauer). A Magyar Tudományos Akadémia Elhunyt Tagjai Fölött Tartott Emlékbeszédek (Memorial Speeches Held Over the Deceased Members of the Hungarian Academy of Sciences) XI, no. 5 (Budapest: Magyar Tudományos Akadémia, 1902). Also see entry on Laufenauer in József Szinnyei, Magyar írók élete és munkái (The Life and Work of Hungarian Writers), Vol. 7 (Budapest: Saád-Steinensis, 1908), 866–870. 41. Kétly (1902), 2. 42. See Moravcsik (1906b), 82–95; Schaffer (1928), 243–247; Kétly (1902). 43. See ibid. 44. Endre H˝ ogyes, ed., Emlékkönyv a Budapesti Királyi Magyar Tudományegyetem Orvosi Karának múltjáról és jelenér˝ol (‘Memorial Book’ on the Past and Present of the Medical Faculty of the Royal Budapest Hungarian University) (Budapest: Athenaeum, 1896), 536–538. 45. Apart from these, he was member of the Royal Society of Budapest Physicians, the National Public Health Society, the Association for Natural Sciences, the Viennese mental pathology association and corresponding member of the Paris Société Mèdico-psychologique. See Szinnyei (1908), 866–870. 46. See János Rigó, ed., A Budapesti Orvostudományi Egyetem jubileumi évkönyve (The Jubilee Yearbook of the Budapest Medical University) (Budapest: Kossuth Nyomda, 1969), 21. Until the 1860s, it only meant a few lectures for those interested. 47. See discussed in Chapter 3. According to Miskolczy, Schwartzer had been unsuccessfully applying for teaching “psychic therapy” (“lélekgyógytan”) as privatdozent at the Medical Faculty for 10 years before he succeeded in 1860. Dezs˝ o Miskolczy, Schaffer Károly (Budapest: Akadémiai Kiadó, 1973), 10. 48. See H˝ ogyes (1896), 536–538, 644–645, 665–667, 710–713, 743–746.

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49. Moravcsik (1906b), 89; Henrik Hollán, Adatok és szemelvények a Szent Rókus Közkórház és fiókjai alapításának és fejl˝odésének történetéb˝ol történetéb˝ol (Data Concerning the History of the Foundation and Development of Saint Roch Public Hospital and Its Wards) (Budapest: Medicina Könyvkiadó, 1967), 83. 50. Laufenauer (1876), 91–92. Laufenauer claims that such clinics with approximately 40 beds in many cases formed the part of state or city hospitals. Also see Laufenauer, Az elmegyógyintézetek túltömöttsége, annak okai és elhárításáról (On the Overcrowdedness of Mental Asylums, Its Causes and Prevention) (Budapest: Franklin Társulat Nyomdája, 1875), 18–20, 27–32; Engstrom (2003). See more discussion of different models of the psychiatric clinic in Germany below. 51. For the plan of establishing the mental pathology department, see Nádudvari (1936), 634–635. See also Moravcsik (1906b), 82–95. 52. For this hostility between the university and the Saint Roch Hospital management and their representatives in the town council, see Nádudvari (1936), 634–635; György Gortvay, Az újabbkori magyar orvosi m˝ uvel˝odés és egészségügy története (The History of Hungarian Medical Culture and Health Care in Modern Times) (Budapest: Akadémia Kiadó, 1953) 84. 53. Moravcsik (1906b), 82–95. 54. In 1861 Pest council supported Dr. Bartha to establish a special ward for nerve-patients at Saint Roch Hospital, and at the same time Dr. Flór was planning to open a small ward for “mental and nervous patients” (“szellem- és idegbajosok”) within the framework of the I. medical department. See Kálmán Pándy, Gondoskodás az elmebetegekr˝ol más államokban és nálunk (The Care for Mental Patients Abroad and in Our Country) (Gyula: Corvina, 1905), 371. In 1864, the “Szerkeszt˝ oségi” (Editorial) of Orvosi Hetilap (Medical Weekly) stated that there were plans to establish a special ward for “convicts and mental patients,” see “Szerkeszt˝ oségi” (Editorial), Orvosi Hetilap (Merdical Weekly) 8 (1864), 135. Between 1866 and 1868, Károly Bolyó was physician at the observation ward of Saint Roch Hospital until he became ward doctor at the newly opened Lipótmez˝ o State Asylum.

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55. See H˝ ogyes (1896), 536–538, 644–645, 665–667, 710–713, 743–746; Moravcsik (1906b), 82–95; Moravcsik (1906a), 38– 42. 56. See H˝ ogyes (1896), 536–538, also 644–645, 665–667, 710–713, 743–746. 57. The treatment of less serious nervous problems could be well managed on an outpatient-basis at the clinic. Mental patients, especially with grave affliction, were usually sent over to asylums, while less serious cases were kept at the ward for patient demonstration for a short period of time. 58. Many hundreds of case histories at Lipotmez˝ o public asylum I checked testify that a large portion of the asylum population recruited from the capital came via Laufenauer’s observation ward. 59. These numbers are also given by Laufenauer (1886), 134–135. 60. As a good example, see discussion of hypnosis research at the clinic in the second part of the chapter. 61. In 1882, there were 40 beds, by 1901, the capital gradually enlarged it to 150 beds. Laufenauer, however, stated that these “measures always bore the sign of provisionality.” See Károly Laufenauer, “Budapest székes f˝ ováros elmebetegügye” (Mental Health Care of Budapest), in Az 1900. évi október 28–29-én Budapesten tartott Els˝o Országos Elmeorvosi Értekezlet munkálatai (Proceedings of the First National Alienist Congress, Held in Budapest, on 28–29 October 1900), ed. László Epstein (Budapest: Pallas, 1901), 135–137. 62. Moravcsik (1906b), 90–92. 63. Ibid. 64. The example of the case of the Hungarian “star” hypnotised patient, Ilma, treated by Laufenauer, Schaffer and Jendrássik, itself contained all these elements. See Emese Lafferton “Hypnosis and Hysteria as Ongoing Processes of Negotiation: Ilma’s Case from the Austro-Hungarian Monarchy”, History of Psychiatry 50 (2002), 177–196; 51 (2002), 305–327. 65. For criminals taken to the observation ward, this was the last place before the prison where escape was relatively easy. In December 1886, Róza Békési (the female thief sought after by the police) was stabbed in the street and taken to Saint Roch Hospital. Her boyfriend almost succeeded in helping Róza escape from

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the hospital (and from the legal procedure) under the disguise of street clothes. See Pesti Hírlap (Pest Gazette), “Megakadályozott szökés” (Prevented Escape), December 16, 1886, 7. The servant Márta Mészáros, being cured of her disease (presumably hysteria) by the doctors, escaped legal procedure by sneaking out through the door in ordinary dress while her friend talked to the janitor to distract his attention. See Pesti Hírlap (Pest Gazette), “Megszökött beteg” (Escaped Patient), April 3, 1885, 6. 66. See Róza Weisz, Teréz Kehl, and Béla Grünwald’s cases in Pesti Hírlap (Pest Gazette), “Álbetegek” (Pseudo Patients), December 15 and 17, 1886, 7–8. 67. See Pesti Hírlap (Pest Gazette), “Kórházak túlzsúfoltsága” (Overcrowded Hospitals), January 10, 1887, 6; January 19, 1887, 7; and February 12, 1887, 6. 68. Pesti Hírlap (Pest Gazette),” A Rókus-kórház borzalmai (Fojtogató o ˝rült)” (The Horrors of Saint Roch Hospital [The Mad Strangler]), July 29, 1887, 4–5. 69. Pesti Hírlap (Pest Gazette), “A rókuskórházi véres eset” (The Bloody Case of Sain Roch Hospital), July 30, 1887, 5–6. 70. Pesti Hírlap (1887) “Fojtogató o ˝rült”, 4. 71. The Budapest Hírlap mentions that the five cells were equipped with furniture made of iron specially for “mad people”, calm mental patients were placed here in pairs or sometimes four. See Budapesti Hírlap (Budapest Gazette), “Gyilkos o ˝rült” (The Mad Murderer), July 29, 1887, 3. 72. Pesti Hírlap (1887) “Fojtogató o ˝rült”, 4. 73. Budapesti Hírlap (1887) “Gyilkos o ˝rült”, 3. 74. Pesti Hírlap (1887) “Véres eset”, 5. 75. Budapesti Hírlap (1887) “Gyilkos o ˝rült”, 2. 76. Pesti Napló (Pest Journal), “Gyilkosság a Rókus-kórházban” (Murder in Saint Roch Hospital), July 28, 1887. 77. Budapesti Hírlap (1887) “Gyilkos o ˝rült”, 2. 78. Pesti Hírlap (1887) “Fojtogató o ˝rült”, 5. 79. F˝ovárosi Lapok (Capital Daily), “A kórházi áldozat” (The Hospital’s Victim), July 30, 1887, 1533. 80. See Budapesti Hírlap (1887) “Gyilkos o ˝rült”, 3 and Nemzet (Nation), “Vizsgálat a Rókus-kórházban” (Investigation in the Saint Roch Hospital), July 30, 1887.

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81. See Laufenauer’s description of the clinic in H˝ ogyes (1896), 536– 538. 82. See ibid. 83. Miskolczy (1973), 42–43. 84. See Laufenauer’s description of the clinic in H˝ ogyes (1896), 536– 538. 85. Laufenauer (1901), 136. 86. See Laufenauer’s description of the clinic in H˝ ogyes (1896), 536– 538. 87. Laufenauer’s response to Salgó’s presentation, Salgó (1901), 86. 88. See Kétly (1902) and Moravcsik (1906b), 82–95. 89. Laufenauer (1901), 136. 90. Salgó’s response to Laufenauer’s lecture at the 1900 National Congress of Alienists, see Laufenauer (1901), 138. 91. See Károly Vörös, ed., Budapest története (The History of Budapest), Vol. IV (Budapest: Akadémia Kiadó, 1978), 377. 92. Engstrom (2003), 3–4. 93. Ern˝ o Jendrássik, “A budapesti kir. magyar tudományegyetemen az idegbajosok klinikájának megnyitó el˝ oadása” (Lecture at the Opening of the Nerve-Clinic of the Budapest Royal Hungarian University), Orvosi Hetilap (Medical Weekly) 41 (1902), 656– 658; 42 (1902), 673–675. 94. See Ferencz Herzog’s obituary on Jendrássik: Ferencz Herzog, “Jendrássik Ern˝ o emlékezete” (The Memory of Ern˝ o Jendrássik), Orvosképzés (Medical Education) 4 (1922), 373–391. 95. See Laufenauer and Jendrássik’s chapters in Árpád Bókay, Károly Kétly and Frigyes Korányi, eds., A belgyógyászat kézikönyve (Handbook of Internal Medicine), Vol. 6 (Budapest: MOKT, 1899), and Ern˝ o Jendrássik, ed., A belorvostan tankönyve (Textbook of Internal Medicine), Vol. 2 (Budapest: Universitas Könyvkiadó Társaság, 1914). 96. See Schaffer (1925), 133–136. 97. Moravcsik (1906a), 38. ˝ 98. See Lóránt Leel-Ossy, “A magyar—német neuropatológiai kapcsolatok története” (The History of Hungarian-German Neuropathological Relations), Orvosi Hetilap (Medical Weekly) 147, no. 26 (2006), 1235–1239. 99. Moravcsik (1906a), 38.

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100. Gyula Niedermann, “A terjed˝ o hüdéssel járó butaság” (Dementia Paralytica Progressiva), Orvosi Hetilap (Medical Weekly) 48 (1865), 975–981; 49 (1865), 999–1009. 101. Károly Laufenauer, “Felhágó hüdéses butaság egy esete. Adat a gerincagy-rendszer betegségeihez” (A Case of Paralysis Progressiva. Contribution to the Diseases of the Spinal Cord), Orvosi Hetilap (Medical Weekly) 11 (1878), 201–205; 15 (1878), 290– 297. 102. Károly Laufenauer, “A terjed˝ o hüdéses butaság kórképe, kóroktana, és kórbonctana” (The Clinical Picture, Aetiology, and Morbid Anatomy of Paralysis Progressiva) Orvosi Hetilap (Medical Weekly) 4 (1879), 61–66; 5 (1879), 86–89. 103. Károly Laufenauer, “Az agy, kis agy, nyúlt- és gerincagy idegeinek kórszövettanni elváltozásairól górcsövi izzadvány, folyamatok behatása alatt” (On the Histological Lesions of the Nerves in the Brain, the Cerebellum, the Medulla Oblongata, and the Spinal Cord), Orvosi Hetilap (Medical Weekly) 16 (1879), 333–336; 17 (1879), 353–358. 104. Károly Laufenauer, “Az epilepsia és az epileticus elmebántalmak kórbonctanáról” (The Morbid Anatomy of Epilepsy and Epileptic Mental Disorders), Orvosi Hetilap (Medical Weekly) 45 (1879), 989–995; 46 (1879), 1009–1017. 105. Károly Laufenauer, “A másodlagos terjed˝ o hüdéses butaságról” (On Secondary Paralysis Progressiva) Orvosi Hetilap (Medical Weekly) 31 (1882a), 792. 106. As Laufenauer’s assistant, Schaffer sarcastically called it. 107. Miskolczy (1973), 43–45. 108. Ibid., 19–27. For Schaffer’s life, also see Szinnyei (1908), 312– 313. 109. See József Hámori, “A magyar agykutatás száz éve: 1870–1970” (One Hundred Years of Hungarian Brain Research: 1870–1970), Magyar Szemle (Hungarian Review) 8 (2000). 110. Miskolczy (1973), 30–33. 111. For his clinical work, see: Károly Schaffer, Az ideg- és elmebetegségek therapiája (The Therapy of Nervous and Mental Diseases) (Budapest, 1893d) and Károly Schaffer, Általános elmekórtani diagnostica (Klinikai Diagnosztika kézikönyve) (General Diagnostics in Mental Pathology [The Handbook of Clinical Diagnostics]) (Budapest, 1893e).

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112. Miskolczy (1973), 53–55. 113. Ibid., 58–60. 114. See Károly Schaffer, “A neurontan hystologiai és pathologiai szempontból” (The Neuron Theory from Hystological and Pathological Perspectives), Budapesti Orvosi Újság (Budapest Medical Newspaper) (1904) 2, 921. Károly Schaffer, “A neurontan hystologiai és pathologiai szempontból” (The Neuron Theory from a Hystological and Pathological Perspective), in Az 1904. évi október 23-án és 24-én Budapesten tartott Harmadik Országos Elmeorvosi Értekezlet munkálatai (Proceedings of the Third National Alienist Congress, Held in Budapest, on 23–24 October 1904), ed. László Epstein (Budapest: Schmidl Sándor Könyvnyomdája, 1905a), 106–123. 115. József Hámori, “A neurobiológia magyar nagyjai az elmúlt évszázadban (1870–1970)” (The Hungarian Giants of Neurobiology During the Past Century [1870–1970]), in Közgy˝ ulési el˝oadások 2000. november. 175 éves az MTA (Lectures at the General Assembly of November 2000. The Hungarian Academy of Sciences Is 175 Years Old), ed. Ferenc Glatz, Vol. II (Budapest: ˝ MTA, 2002), 441–451. On Schaffer’s work also see Leel-Ossy (2006), 1235–1239 and Miskolczy (1973). 116. See Hámori (2002), 443; Miskolczy (1973), 10, 18–22; Károly Schaffer, “Ueber die Anatomie und Klinik der TaySachs’schen amaurotisch-familiären Idiotie mit Rücksicht auf verwandte Formen,” Zeitschrift für die Erforschung und Behandlung des Jugendlichen Schwachsinns auf wissenschaftlicher Grundlage (1909) no. 3, 147–186; Károly Schaffer “Ueber einen Fall von Tay-Sachs’scher amaurotischer Idiotie mit Befund,” Wiener Klinische Rundschau (1902) no. 16, 324–325; Károly Schaffer, “Zur Pathogenese der Tay-Sachsschen amaurotischen Idiotie”, Neurologische Zentralblatt (1905b) no. 24, 386–392. 117. I only briefly discuss it here as it will be part of my next book on the “sciences and cults of the mind,” which will explore the history of mesmerism, spiritualism, hypnosis and hysteria in the context of science, culture and modernity in Central Europe in the long nineteenth century. 118. See Endre H˝ ogyes, “A hypnotismus tüneményeinek ismeretéhez” (To Our Knowledge on Hypnotic Phenomena), Természettudományi Közlöny (Natural Scientific News) 175

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(1884), 131–133; Endre H˝ ogyes and Károly Laufenauer, “A hypnotismus t˝ uneményeinek bemutatása méhszenves nehézkórosokon” (Demonstration of Hypnotic Phenomena in Hystero-Epileptic Patients), Gyógyászat (Medicine) 11 (1884a), 181–183, 188–190. 119. Endre H˝ ogyes and Károly Laufenauer, “A hypnotismus tüneményei a Szent Rókus Közkórházban fekv˝ o három hysteroepileptikus betegen” (Hypnotic Phenomena in the Case of Three Hystero-Epileptic Patients at Saint Roch Hospital), in A Budapesti Királyi Orvosegyesület 1884.-diki évkönyve (The 1884 Yearbook of the Budapest Royal Association of Physicians), ed. Imre Réczey (Budapest: Khór és Wein Könyvnyomdája, 1884b), 32. 120. H˝ ogyes and Laufenauer (1884b), 35. 121. He refined Pasteur’s vaccination technique which subsequently became widely used in many countries. He also established the Pasteur Institute in 1890. 122. Endre H˝ ogyes, “A reflexjelenségekr˝ ol hisztero-epilepsziás betegen” (On Reflex-Phenomena in a Hystero-Epileptic Patient), Természettudományi Közlöny (Natural Scientific News) 24 (1892), 652–653; Endre H˝ ogyes, “Hypnosis kísérlete” (A Hypnotic Experiment), Természettudományi Közlöny (Natural Scientific News) 24 (1892), 386; Károly Schaffer, “A suggestio hatása a reflexekre” (The Influence of Suggestion on the Reflexes), Természettudományi Közlöny (Natural Scientific News) 24 (1892), 653; Károly Schaffer, “Hypnotikus kísérletek” (Hypnotic Experiments), Orvosi Hetilap (Medical Weekly) 18 (1892), 227; Károly Schaffer, “Látóhártya-reflexek a hypnosis alatt” (Retina-Reflexes under Hypnosis), Orvosi Hetilap (Medical Weekly) 2 (1893a), 19–24; Károly Schaffer, “Az intrahypnotikus reflexcontracturák morphologiája és a suggestiónak behatása ezekre” (The Morphology of Intrahypnotic Reflex-Contractions and the Influence of Suggestion on It), Orvosi Hetilap (Medical Weekly) 47 (1893b), 565–566; Károly Schaffer, “A hallásról, suggerált süketségben” (On Hearing after Suggested Deafness), Természettudományi Közlöny (Natural Scientific News) 25 (1893c), 645. 123. Károly Schaffer, “Az intrahypnotikus reflexcontracturák morphologiája és a suggestionak behatása ezekre” (The

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Morphology of Intrahypnotic Reflex-Contractions and the Influence of Suggestion on It), Értekezések a Természettudományok Köréb˝ol (Dissertations from the Field of the Natural Sciences) 23, no. 11 (1894), 687–759; Károly Schaffer, A hypnotismus élettani, gyógytani és törvényszéki szempontból (Hypnotism from Physiological, Therapeutic and Forensic Perspectives) (Budapest: Dobrowsky és Franke, 1895a); Károly Schaffer, Suggestion und Reflex, eine kritisch-experimentelle Studie über die Reflexphänomene des Hypnotismus (Jena: Fischer, 1895b). 124. Negative suggestions mostly were the suggestion of a lack of a certain sensation, like deafness, blindness, lack of skin-sensitivity or taste, anosmia, thus bringing about a lack of reflex functions in the certain body part. See also: Schafferv (1892), (1893a), (1893b), (1893c). 125. On the role of the experimental subject in experimental psychology, see Martin Kusch, Psychological Knowledge: A Social History and Philosophy (London and New York: Routledge, 1999). 126. See Károly Laufenauer, “A hypnotismus és a vele rokon ideges tünemények” (Hypnotism and Related Nervous Phenomena), Természettudományi Közlöny (Natural Scientific News) 178 (1884): 233–250; 179 (1884): 273–286. 127. Schaffer (1895a) 38–39. 128. For Jendrássik’s life, see Szinnyei (1908) and Herzog (1922). 129. His classification of the different reflexes and method of observing weak reflex activity became internationally accepted and the latter was named after him. 130. See Ern˝ o Jendrássik, “Hypnoticus suggestio kísérletek” (Experiments with Hypnotic Suggestion), Gyógyászat (Medicine) (1887), 140–142; Ern˝ o Jendrássik, “A suggestióról” (On Suggestion), Orvosi Hetilap (Medical Weekly) 23 (1888a), 746–749, 781–785; Ern˝ o Jendrássik, “A hysteriás suggerálhatóságról” (On Hysterical Suggestibility), Orvosi Hetilap (Medical Weekly) 42 (1892): 508–510; 43 (1892): 523–525; 44 (1892): 537–539; 45 (1892): 551–553. 131. See the debate following his presentation in Jendrássik (1887). 132. See Jendrássik (1888a). For similar experiments and his papers on hypnosis in general, see Ern˝ o Jendrássik, “A hypnotismusról”

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(On Hypnotism), Orvosi Hetilap (Medical Weekly) 2 (1885), 29– 34; 3 (1885), 53–58; 4 (1885), 88–92; Ern˝ o Jendrássik, “De l’hypnotisme,” Archives de Neurologie 11 (1886), 362–380; 12 (1886), 43–53. 133. In the same year, Gyógyászat (Medicine) reported of the 1889 International Congress of Alienists in Paris dedicated to experimental and therapeutic hypnotism. There the questions of the prohibition of open hypnotic sessions and the regulation of the practice of hypnosis by the authorities were widely discussed. See “Beszámoló az 1889-es párizsi Nemzetközi Pszichiátriai Kongresszusról” (Report on the 1889 International Congress of Alienists in Paris), Gyógyászat (Medicine) 36 (1889), 429–430. 134. Ödön Blum, “Szabad-e hypnotizálni?” (Is Hypnosis Permissible?), Gyógyászat (Medicine) 31 (1889a), 361–362. 135. In his authoritative book, Schaffer stated that verbal suggestion was very successful in some nervous diseases (although more difficult in cases of neurasthenia and hysteria, and epilepsy), but found that “real” mental patients were not hypnotisable at all. If they were suggestible, they could not be mentally ill. See Schaffer (1895a), 58. 136. Blum (1889). 137. See Jakab Salgó, “A hypnotismus tudományos és gyógyértéke” (The Scientific and Therapeutic Value of Hypnotism), Klinikai Füzetek (Clinical Papers) 5 (1896a), 10–11. 138. Ibid., 13, 17. 139. Ibid., 15–16. 140. For the study of the case and its international relevance, see Emese Lafferton, “Murder by Hypnosis? Altered States and the Mental Geography of Science,” in Medicine, Madness and Social History: Essays in Memory of Roy Porter, ed. John Pickstone and Roberta Bivins, (New York: Palgrave Macmillan, 2007), 182–196. 141. 19 December 1894, No. 103,816 decree issued by the Ministry of Interior, in Kornél Chyzer ed., Az egészségügyre vontakozó törvények és rendeletek gy˝ ujteménye. 1854–1894 (Collection of Laws and Decrees Concerning Health Care. 1854–1894) (Budapest: Dobrowsky és Franke, 1894), 752. 142. Gyula Donáth, “Spiritismus által el˝ oidézett hystero-epilepsia esete” (A Case of Hystero-Epilepsy Caused by Spiritism). In

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Az 1902. évi október 26-án és 27-én Budapesten tartott Második Országos Elmeorvosi Értekezlet munkálatai (Proceedings of the Second National Alienist Congress, Held in Budapest, on 26–27 October 1902), ed. László Epstein, 222–229 (Budapest: Schmidl Sándor Könyvnyomdája, 1903). 143. Schaffer (1895a), 77–79. 144. See Pál Ranschburg, “Módszerem és készülékem az emlékez˝ o er˝ o vizsgálatára” (My Method and Machine for the Study of the Memorial Power), in Az 1900. évi október 28–29-én Budapesten tartott Els˝o Országos Elmeorvosi Értekezlet munkálatai (Proceedings of the First National Alienist Congress, Held in Budapest, on 28–29 October 1900), ed. László Epstein (Budapest: Pallas, 1901), 111–118. Sources demonstrate that Lechner was the other person who first used different experimental psychological tools in his neurological research, and the later eminent philosopher, Menyhért Palágyi also conducted experiments at Lechner’s laboratory. See Károly Lechner, “Az izommunka szerepköre értelmi m˝ uveleteinkben, tekintette a testgyakorlásra” (The Role of Muscle Work in Our Intellectual Functions, With Special Focus on Body Excercise), Gyógyászat (Medicine) 40 (1890), 469–473; 41 (1890), 481–485; 42 (1890), 494–500; Károly Lechner, “Psychomechanicai törekvések az elmegyógyászatban” (Psychomechanical Attempts in the Treatment of Mental Illness), in Az 1900. évi október 28–29-én Budapesten tartott Els˝o Országos Elmeorvosi Értekezlet munkálatai (Proceedings of the First National Psychiatric Congress, Held in Budapest, on 28–29 October 1900), ed. László Epstein (Budapest: Pallas, 1901), 66–82; Menyhért Palágyi, “A reakcióid˝ o kísérleti elemzése” (The Experimental Analysis of Reaction Time), in Az 1906. évi október hó 29-én és 30-án Budapesten tartott negyedik országos elmeorvosi értekezlet munkálatai (Proceedings of the Fourth National Alienist Congress, Held in Budapest, on 29–30 October 1906), ed. László Epstein (Budapest: Pesti Könyvnyomda, 1907), 134. Also see Csaba Pléh, A lélektan története (The History of Psychology) (Budapest: Osiris, 2000), 277. According to Pléh, the first coherent work on German experimental psychology was written by Gyula Kornis in 1911. See also Katalin Fodor and Béla Kós, “Lechner Károly, a

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‘psychophisiológia’ kolozsvári m˝ uvel˝ oje” (Károly Lechner, Scientist of Psychophysiology in Kolozsvár), in Pszichológia Magyrországon (Psychology in Hungary), ed. György Kiss (Budapest: Országos Pedagógiai Könyvtár és Múzeum, 1995), 20–31. 145. See Ágnes Torda, “Egy tudományos m˝ uhely létrejötte a századfordulón” (The Emergence of a Scientific Workshop at the Turn of the Century), in Pszichológia Magyarországon (Psychology in Hungary), ed. György Kiss (Budapest: Országos Pedagógiai Könyvtár és Múzeum, 1995), 31–56. See also Gusztáv Lányi ed., Ranschburg Pál és a magyar pszichológia (Pál Ranschburg and Hungarian Psychology) (Budapest: ELTE Eötvös Kiadó, 2013). 146. Miskolczy (1973), 58–60. 147. In 1908, it was opened as University Mental Clinic but next year was renamed as University Clinic of Mental and Neuro-pathology. See Nádudvari (1936), 720. 148. See Ern˝ o Moravcsik, “A budapesti királyi tudomány-egyetem elmekórtani klinikája” (The Mental Clinic of the Budapest Royal University), in Elme- és Idegkórtan (Mental and NeuroPathology), ed. Ottó Babarczi Schwartzer and Ern˝ o Moravcsik (Budapest: A Pesti Lloyd Társulat Könyvnyomdája, 1908), 168– 172. Also see Nádudvari (1936), 715–720. 149. See Ferenc Pisztora, “A 100 éves budapesti Pszichiátriai Tanszék és Klinika kezdeti id˝ oszaka” (The Early Phase of the HundredYear-Old Budapest Psychiatric Department and Clinic), Ideggyógyászati Szemle (Neurological Review) 36 (1983), 206. 150. See descriptions of his experiments in Ern˝ o Moravcsik, Az associatiót el˝osegít˝o és gátló tényez˝ok (Factors Supporting and Inhibiting Association) (Budapest: Franklin, 1910); Ern˝ o Moravcsik, A suggestió befolyása a gondolkodásra és cselekedetekre (The Influence of Suggestion on Thinking and Acting) (Budapest: Márkus Samu Könyvnyomdája, 1913). 151. See Jendrássik (1914), 448–449. 152. See Pál Harmat, Freud, Ferenczi és a magyarországi pszichoanalízis (Freud, Ferenczi and Hungarian Psychoanalysis) (Budapest: Bethlen Gábor Könyvkiadó, 1994), 93–97. 153. See Harmat (1994), 56 and section on Ferenczi in Chapter 8. 154. According to Brigitta Baran et al., Schaffer’s failure to achieve further achievements of international standard towards the latter part of his career was due to the fact that he failed to integrate in

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his institute’s work other novel and promising disciplines of the time, such as physiology and biochemistry, he had “no other ‘wet’ bench sciences to underpin” his work on heredodegeneration. See Brigitta Baran, István Bitter, Max Fink, Gábor Gazdag, Erward Shorter, “Károly Schaffer and His School: The Birth of Biological Psychiatry in Hungary, 1890–1940,” European Psychiatry 23 (2008), 452.

CHAPTER 6

Fragmenting Institutional Landscape. Alternatives of Specialised Institutions, Colonies and Family Care on the Turn-of-the-Century

The Relationship of Academic and Asylum Psychiatry As we saw in the previous chapter, the Budapest Department of Mental Health and Pathology and its related clinic provided the conditions for the growth of academic psychiatry and the beginning of original research in Hungary. Their appearance signifies the process of institutional and intellectual expansion of psychiatry within the medical sciences and fragmentation within the psychiatric profession: the emergence and spread of new forms of enquiry, practices and theories. In the 1880s, this process did not yet create a chasm between alienists and university psychiatrists as occurred in Germany, France and Austria. In both Germany and Austria, the establishment of the psychiatric clinic and the introduction of scientific research were met by fierce opposition in the ranks of traditional alienists (asylum doctors). Alienists’ more patient-centred view and humanistic ideals made them adverse to such new institutions (often established in urban centres seen as highly aggravating patients’ conditions) and often claimed that these novel forms of psychiatric practices (for instance, patient demonstration to medical

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 E. Lafferton, Hungarian Psychiatry, Society and Politics in the Long Nineteenth Century, Mental Health in Historical Perspective, https://doi.org/10.1007/978-3-030-85706-6_6

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students) could be directly disadvantageous to mental patients. Professional interests also obviously clashed which further explain asylum psychiatrists’ scepticism concerning these elite academic institutions mushrooming on German lands. Thus, psychiatric clinics emerged in the midst of controversies between alienists and university psychiatrists.1 In Austria, a similar conflict surrounded Meynert’s professional activities at the mental asylum years before his psychiatric clinic was set up in 1870. From 1866, when Meynert began his work as neuro-anatomist and prosector at the asylum, Riedl’s students who endorsed the psychological approach that characterised the previous decades and were occupied with issues of improving life and treatment conditions within the asylum, the introduction of no-restraint system, and legal regulation of mental health care, were understandably adverse to Meynert’s work. The conflict finally lead to the Lower Austrian Provincial State Commission’s (administrative directorate of the mental asylum) demand of Meynert’s resignation.2 This was the occasion that prompted Rokitanski in 1875 to set up for Meynert a second department of psychiatry with an observation ward at the General Hospital; a solution that was rather surprising given the fact that psychiatry at the time was not an obligatory subject.3 French psychiatry in the second part of the nineteenth century was similarly characterised by bitter hostility between practitioners in distinct types of psychiatric institutions.4 In Hungary, initial opposition to academic research is hardly graspable before and during the early 1880s. Conflicts due to differences between the perspectives and professed ideals of asylum doctors and university psychiatrists became manifest only in the late 1880s–1890s, when disillusionment with neuro-anatomical and physiological research increased due to its inability to lead to therapeutic developments in the field. The reasons for this early lack of hostility are manifold. It could be explained by the fact that the Hungarian history of institutionalised psychiatry is shorter and, in a sense, more condensed than that of other national psychiatries in the West, and that, due to the relatively low degree of institutionalisation, to more uniform early training and possibilities for acquiring practical experience, the psychiatric elite was rather small and like-minded. With only a few asylums appearing from the 1860s, the asylum psychiatry tradition was not as long and deeply rooted as in other countries, although most first-generation professionals started their career at an asylum.

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By the 1880s, Ferencz Schwartzer was hardly active and was reliant on his son under whose work laboratory investigations were included into the daily duties of doctors at the private asylum.5 The other eminent representative of the older generation of asylum doctors, Gyula Niedermann, was not hostile either to neuro-pathological research. His 1865 article in the Orvosi Hetilap (Medical Weekly) was among the first articles on the neuro-pathological aspects of paralysis I found in the Hungarian literature. For the second generation of psychiatrists in the country, learning and acquiring experience in mental pathology was confined to the capital. Bolyó, Laufenauer, Konrád and Lechner were trained at the Budapest Medical Faculty6 and first encountered mental patients in the Schwartzer asylum or among other Schwartzer students at Lipótmez˝ o. All this resulted in a more closely connected professional elite and perhaps a less hostile environment in the first phase of psychiatric professionalisation between the 1860s and 1880s. Without downplaying the importance of possible early differences within this environment, these differences did not become manifest until professional publications began to spectacularly multiply under more varied authorship at the end of the 1880s (in articles as well as textbooks). Laufenauer’s person is also crucial in this respect. He became influential and respected by the 1880s and remained so until his death in 1901, and many of the subsequent psychiatrists were trained under him. His personal and professional attitude was thus of considerable influence. Due to his varied experience in asylum work as well as in academic research made his understanding of the nature of mental illness and the functions of psychiatry more complex. Under his leadership, the psychiatric clinic became a place for the central distribution of patients in the network of mental institutions in which distinct mental institutions had their own place and role. As the leading figure in academic psychiatry, he did not call into doubt the legitimacy of asylum psychiatry and rather than sharpening the oppositions, his work was instrumental in integrating the institutionally and intellectually fragmenting profession by the end of the century. As we saw in the previous chapter, hypnosis and hysteria research in the late 1880s–1890s stemming from Laufenauer’s clinic (and Jendrássik’s similar internal clinic) is nevertheless useful in demonstrating the start of deepening intellectual and institutional divisions within the profession. Yet it was not just the case of hypnosis where the opposition between asylum and academic psychiatry became visible: discontent and problems within psychiatry were far deeper. While laboratory investigation brought

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about the development of new biomedical sciences, therapeutics lagged behind other branches of medicine. In psychiatry, the concentration on brain anatomy and the patho-physiological and neurological mechanisms of psychiatric disorders first gave rise to great hopes but in the end failed to advance therapeutics. These new studies confirmed the organic nature of some mental diseases (like the cause of paralysis by neurosyphilis) and claimed that some of their underlying pathological processes were irreversible. This was coupled with the disastrous conditions at overcrowded asylums and hospital wards as a result of which a general therapeutic pessimism or “nihilism” pervaded psychiatry.7 By the 1890s, this disillusionment with the usefulness of neuroscientific research from a practical therapeutic psychiatric point of view is apparent in Hungary. While numerous articles and mental pathology textbooks from the 1880s included a discussion of neurological findings related to certain disease forms, in his book published in 1890, the Lipótmez˝ o doctor Salgó explained his almost complete neglect of neurological and histological explications with the verdict that “all the great hopes that a decade earlier still surrounded pathological and anatomical studies were in vain.” He believed that “the anatomical basis of mental illnesses is still an undiscovered area, and is a question for the future if it will ever be mapped.”8 He admitted that anatomical research had produced knowledge concerning the function of the central nervous system, but this still added little to the development of mental pathology, and did not bring doctors any closer to therapy.9 Salgó spoke for the asylum clinician who found it crucial to shift the attention to the brain and nerves back to the living patient and the manifestations of his illness. A debate between Salgó and Laufenauer at the 1900 First National Alienist Congress highlights the rivalry between the asylum and the university clinic. In discussing what kind of psychiatric knowledge and experience students should acquire during their university studies, the asylum doctor Salgó spoke for alienists and clinicians. He emphasised the importance of clinical practice, since “medicine is a science directed towards practice par excellence.” He claimed that exclusive medical practice at the university clinic was insufficient for students since the long-term observation of patients and the physical and psychic manifestations of their illness was impossible. Most patients were retained only for a short time, and very rarely for the entire period of their mental illness. This, as well as the administrative and forensic aspects of the psychiatrist’s work, he asserted, could only be studied in depth in the asylum. Thus, he found

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it necessary even for general doctors to spend a few compulsory months at a large asylum during their medical practice.10 Laufenauer rejected this idea by downplaying the necessity of student medical practice at asylums. He realised that the failures witnessed by the last years of the nineteenth century had shattered both the traditional asylum and the histological and neuro-pathological research centres. Neither treatment in overcrowded asylums, nor narrow attention on neural research which, for a while, vindicated exclusive scientific status for itself at the expense of clinical investigation, had brought much success in the treatment of patients.11 In Laufenauer’s mind, the solution was integration of different psychiatric approaches. Thus, he emphasised the combined teaching of mental and nervous disorders at the clinic, “since the two disciplines are inseparable,” believing that a doctor without a sound basis in nervous disorders and neurology could not grasp mental illnesses.12 An integrated basic knowledge in psychiatry was also perhaps necessary in the light of the institutional fragmentation that would be happening in the coming decades.

Old Problems, New Ways. Alternatives to the Mental Asylum ... general poverty and lack of resources also afflict the state, the harmful consequences of which are shared by all the hospitals and doctors, but especially us, alienists, who are obliged to conduct our activities in the four state mental asylums and several smaller or larger mental wards at public hospitals which serve the 20 million population. Our state mental asylums are old, their system and equipment in many respects do not satisfy modern expectations … The number of patients they house exceeds twice or three times the number they can accommodate … [thus] making the proper grouping of patients as well as their nursing and treatment impossible. Today the exclusive goal of our institutions is to safeguard and crowd a small portion of the mentally disordered who pose a threat to society.13

By 1900, four public state mental asylums (formally named: State Mental Institutes) existed in the country. Built in Transylvania, Nagyszeben asylum (with 200 beds and opened in 1863) had a special patient population recruited from that region, while Lipótmez˝ o (1868) served a national function, with a shifting proportion between patients

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from the capital and those from the country. While only curable and dangerous patients were supposed to be admitted to Lipótmez˝ o, it housed numerous incurables as well, even though most of them were eventually transferred to Eger Hospital of the Hospitaller Order, turning that institution into a “dumping ward” for the most hopeless cases. To rid Lipótmez˝ o of incurables, a third public state institution (asylum) was built in Angyalföld (Budapest) in 1884, with 254 beds. Originally Angyalföld was to admit only incurable and dangerous mental patients, but in practice it also admitted curable ones.14 To ease overcrowdedness, the Hungarian government provided 300 more beds for mental patients by turning the old county hall of Szabolcs county in Nagykálló into a fourth public state mental institution (asylum) in 1896. By the 1880s, Lipótmez˝ o and Nagyszeben asylums were overcrowded by patients, among them numerous hopeless cases. The quote above by the alienist Villibald Strobl is revealing about the general conditions that prevailed in these institutions. Around 1900, psychiatrists saw the source of all problems in the very low level of institutionalisation in the country, they therefore lobbied for further mental institutions to be built, but no longer in the monolithic “block-system.” The asylum director Gusztáv Oláh argued for the establishment of larger institutions which did not form a “single complex,” but rather constituted an “integrated unit” which allowed for a great degree of differentiation so that the “patient could be easily moved along the different milieus necessary in distinct phases of his disease-cycle.”15 Director of the Kolozsvár (Cluj) Department and Clinic for Mental and Nervous Pathology, Károly Lechner found the middle-sized institutes with about 400–500 patients the most reasonable, which consisted of several buildings, each suitable for individual disease forms.16 There was probably not a single alienist in the country by the turn of the century who would have preferred the block-system to the pavilion style: an edifice consisting of independent buildings, either completely separate or linked to each other through open galleries, which first appeared in the mid-nineteenth century in general hospital building and by the turn of the century also influenced mental asylum building. The system allowed the separation of patients by disease forms, by severity of the disorders, by degree of agitation, etc.17 These dreams about modern pavilion-style mental institutions were, however, undermined due to lack of resources in Hungary. By comparison, we can see an amazing building boom in mental institutions around 1900 in the Austrian half of the Empire: between

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1898 and 1914, seven brand new mental institutions were established there, two in Lower Austria (Mauer-Öhling and Am Steinhof, the latter the largest institution opened in 1907 with over 2,200 beds and 60 buildings), and one each in Bohemia, Moravia, Galicia, Trieste and Gorizia.18 “Annex Asylums” While lobbying for further “modern” asylums remained on the agenda, the state resorted to a highly criticised but much cheaper solution: forming “annex institutions” or “annex asylums” (the terms designated mental wards attached to public hospitals). Many mental wards were set up at hospitals in the country: in Kaposvár (1880), Szekszárd (1885), Gyöngyös (1896), Nyitra (1898) and Gyula (1898).19 Most psychiatrists were remorselessly critical of this solution. As Kálmán Pándy,20 a psychiatrist with ample experience with this system in a countryside mental ward in Gyula formulated claimed, the two large state mental asylums got rid of their “incurable” patients by sending them to these newly and inadequately set up wards. They lacked professional nurses and psychiatrists: most mental ward doctors in the countryside had no training in mental pathology at all, the wards were run by specialist obstetricians, surgeons and internists. The patients’ admission procedure and conditions at the wards were also not professionally controlled.21 Not only professional treatment was jeopardised in this case, but also personal freedom put at risk. Pándy gave the example of discharges from one of these wards in 1899: 12 “cured” and 10 “improved” patients were discharged without a psychiatrist being present to state this “so difficult criteria of cured status.” Pándy estimated that altogether about 2000 mental patients were kept at these annex wards in the whole country, mostly regarded as “incurables.” Nevertheless, half of them were discharged annually as cured or improved and the same number of 1000 kept for further treatment without any psychiatric control. He feared that “unjustified discharges endangered public safety while a great proportion of the inmates were left imprisoned for a lifetime.”22 This lack of professional control he saw as especially detrimental for patients whose case involved forensic procedures. Perhaps innocently accused of a crime and turned deranged before a judge’s verdict, such a mental patient was likely to be closed up for good based on a forensic doctor’s decision who was often similarly untrained in psychiatry. Thereafter, no countryside doctor

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(also untrained in psychiatry) would dare to question the Board of Forensic Medicine’s (Igazságügyi Orvosi Tanács) decision even if he had observed the patient for the past 4–5 years at the institution and thought otherwise (195). The lack of professional psychiatric control also affected the daily life of these institutions. Pándy gave the example of a young doctor who had only served for a couple of weeks when he resorted to the use of straitjacket in case of a hysterical patient and himself took a nurse’s belt to tie the legs of the patient together with his own hands in order to interrogate the patient about the disappearance of a key (to an inside door, not involving the possibility of escape). Pándy considered this treatment and the example set by the doctor to his nurses utterly unacceptable (196). The lack of professional presence apparently resulted in the neglect of writing case histories. Pándy claimed that “we received more than 100 patients from another caring institute, whose case histories showed no entries for 10-20-25 years,” while “obviously it was impossible to justify the discharge or the further keeping of patients, let alone their move to other institutions, without the conscientious and meticulous case histories” (196). In such institutions mental patients could easily be mixed up with each other, especially when they had difficulties with communication, as evidence showed. Pándy also complained about nursing: untrained and especially aggressive nurses often got away with their behaviour as sacking such staff was in the power of the institute director, rather than the ward doctor. He related a “rare” example when untrained nurses beat a dying paralytic patient to death and would only be rebuked and keep going on with their jobs. The fact that the mental wards were directly subordinated to the hospital director who had no background in mental health care was also why no modernisation was possible at the wards, such as the integration of family and colonial systems with mental institutions (see below) (197). Pándy cynically added that not even cheapness would justify this annex mental ward system, as they cost much more than the existing mental asylums. Annex institutions were small and hence more expensive, their administration less cost effective, catering more expensive, and part of the money that was paid to these hospitals after mental patients was actually not used to satisfy these patients’ needs but rather to cover other priorities of the hospitals unrelated to their mental wards. Finally, Pándy added that mental patients’ work could not be properly utilised, as there was hardly any space and possibility to organise it. To solve the problems, he came

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to the conclusion that the municipalities should build separate mental institutions where costs of nursing and treatment would also be lower, preferably combined with colonies and family treatment (200–203, 205). Furthermore, annex-ward conditions could not be further away from those of the separate and spacious institutes surrounded with parks with an air of space and at least some sense of freedom. As Pándy pointed out, the annex wards were all built in the “costly barrack-style prison-system,” in spite of so many criticisms of it in the past. At the mental ward of the Gyula public hospital, there is approximately 4000 crowns worth of iron bars, 6000 crowns built into stone walls, which nevertheless do not stop one from escaping if he wills, while I could have placed those two or three excited patients into pavilion buildings which would be built from 4-5000 crowns and would be safe as a prison, and then because of those few [excited] patients, 400 people would not have the torturous realisation that they are placed in prisons. Our corridors and empty cells also cost an unnecessary 60-70.000 crowns … (204)23

He added that he would sacrifice electric lighting, steam heating and water system in 9/10 of the institute in exchange for a few houses in the farmland of the Great Hungarian Plain (204). Thus, when the government suggested to create further annex wards instead of large separate institutions, a huge debate arose at the 1900 First National Alienist Congress and most psychiatrists voted for the separate mental asylum rather than the annex institution, heavily criticising the latter. The situation however did not improve much, more and more annex wards were established, and a decade later in 1911, psychiatrists still complained about the annex system, demanded that these wards should have been temporary solutions and separate mental institutions were needed where professional interests and guarantees could prevail, where nursing and medical care could be improved. The gravest problems still concerned the autonomy and professional standards of the mental wards, the subordination of the mental ward director to that of the hospital, etc. “Mental health care must be liberated from the guardianship of hospitals!”24 In 1900 for Pándy, the “better and cheaper solution” was colonies and family care. After the turn of the century, there was a clearly strengthening propagation and sudden success of such alternative formations and treatments.

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Family Care and Colonies Family care meant that patients would be placed to live with foster families for whom it was a way of earning a living. These patients would normally be incurable and not dangerous to their environment (although these were questioned by some professionals), and in practice, mostly released from mental institutions. Family care is not to be mistaken with home care. According to the law, chronic, incurable mentally disordered people not dangerous to the public were not supposed to be institutionalised at all, and they were not the responsibility of the state. Rather, their care had to be provided by their families, or in case of their extreme poverty, arranged by municipalities (“községi ápolás,” community care). “Home and community care are the oldest … forms of mental health care and yet beyond the word of the law, they do not exist.”25 The law clearly defined the requirements of home and community care, but did not ensure its enforcement by the state, hence many patients who should have been in such care roamed freely without any care and help.26 “I have witnessed many cases where mental patients sent to home or community care were kept in prisons, or drifted in abandoned places hungry and thirsty, freezing, and the maximum care they received was tying them down or closing them up”—mental health expert at the Ministry of Interior, Ödön Blum lamented. He also stated that he had no knowledge if any registration of people in home or community care existed at all.27 In the lack of own institutions and resources, municipalities also left these patients with their own families. Director of Nagyszeben State Mental Institute, Jen˝ o Konrád illustrated problems with the system of home care with concrete cases: a mother with three children, 5, 7 and 9 years old, had to take care of the mentally disordered family member. She sent the two bigger children to school, while the smallest child was closed up with the mentally disordered person in the one-room flat for the whole day, so that the mother could go and work (wash) to earn a meagre sum of money to feed the kids. If something tragic happened, the mother would be made responsible for the situation.28 Elsewhere, Konrád recounted the story of an epileptic patient who had spent five years at the Nagyszeben public asylum before he was given to home care “as an experiment.” He received sedatives and was forbidden to consume alcohol. Half a year later he was returned to the mental asylum as dangerous to the public: he drank in a pub and stabbed a young man to death. Konrád claimed that there were many similar cases.29 Konrád thus warned that there was a major

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difference between the ideal of family care and the practice of home care. In the former, “before a patient is given out to a family – either to its own, or another family – it is assessed whether the life circumstances and financial conditions of the certain family enable them to undertake the burden of providing care for the patient,” and “certain regular measures are introduced around both the financial provision as well as the patient’s care and custody.”30 In home care, families often got stuck with such mentally ill family members and were forced to keep them in miserable conditions without much procedural routine (187–188). Importantly, since family care would eventually be connected to newly arranged colonies (even if these were organised around existing institutions), the two terms, family care and colony, became entangled and would be used interchangeably by many of the psychiatrists studied below. The colony was initially and ideally a spacious mental institution set up on a large territory in the countryside, constituted of many small houses rather than huge closed buildings (or one central and several smaller buildings); mostly a self-sustaining economic unit organised around some agricultural or other occupation which also functioned as basis for work therapy.31 On the continent, the widespread system of family care (also often called as colonies) was mostly organised with a “centre,” a medical institution around which the foster families were scattered in neighbouring villages and small towns. There was a wide variety of how these were set up. The “centres” could be existing mental asylums, hospital wards or newly erected buildings of all sizes, and the number of connected families on the “periphery” varied greatly. As opposed to this, in the Scottish system of family care, there was no “centre,” just mental patients put up with families scattered around wide regions. Different forms of control were organised there regionally.32 The colony itself mostly contained the element of family care, if patients were cared for by families in the colony. In the majority of the cases, patients were given out to families other than their own, which was called the “heterofamiliar” system, as opposed to their own families, the so-called homofamiliar system.33 The introduction of family care in Hungary was already proposed in the 1860s by Ferenc Bene, Károly Bolyó and Károly Laufenauer.34 The original model was the Belgian town, Geel, with a still functioning 700-year tradition of taking mentally ill people into homes as boarders and providing care for them. But by the turn of the century, there were different European national traditions to turn to. Several Hungarian medical professionals and a government official thus took

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to road and visited these institutions to gain first-hand experience and then contemplate the best system adaptable to the Hungarian conditions. Gyula Niedermann and Kornél Chyzer (Public Health Councillor at the Ministry of Interior) together went on a study trip to Austria, Switzerland, France and Belgium in 189635 to study different health care institutions, including closed institutions for “idiots,” asylums for alcoholics, tuberculosis clinics, as well as colonies and systems of family care, the result of which was published as their professional recommendations that proved to be highly influential in the coming decade in the establishment of specialised institutes. Concerning colonies: Colonies make the extension of the asylum settlement and accommodation to novel conditions and requirements possible. … The colony has a beneficial impact on the patients’ intellectual welfare and physical health, it makes better use of the patients’ work-power possible, a greater profit can be reaped from the lands, colonial institutions cost less and can be more cheaply sustained. These are great advantages … for an agricultural country such as ours … Such institutes must be built by all means in the pavilion system … Here the patient comes and goes freely to work and feels happier than behind the closed walls of a large, barrack-type asylum.36

At the 1900 First National Alienist Congress , professionals seemed confused on these alternatives and new colonies (i.e. newly established, independent arrangements) yet seemed like a solution in the far future. Gusztáv Oláh, then director of Angyalföld State Mental Institution, gave a presentation on the potential treatment of mental patients in colonies. While he believed that this solution was feasible in Hungary, he did not recommend it for the time being, as he regarded the patient population which crowded contemporary mental asylums as unsuitable for colonial placement.37 Therefore he proposed the combination of the colony with the mental asylum and the “home care” (házi ápolás; he probably meant family treatment but used home treatment instead). The colony would rely on the asylum which then would gain a friendlier character towards the outer world. He believed, together with László Epstein, that mental asylums had to get rid of their “asylum characteristics.”38 Oláh also suggested that municipalities should build colonies for the mentally deranged people they have to care for. There the patients could engage in meaningful work and contribute to the costs of their own care, which would be beneficial to the municipalities and would also ease state

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asylums. Family care should also be organised around existing institutes through the families of the nursing staff. This would solve the “nurse question” as well, Oláh argued, as “nursing vocation only exists where the conditions for establishing a family and final settlement are provided.”39 In the debate that followed, Salgó agreed with Oláh that Hungarian mental health care was not yet on the level to introduce colonies, or even family care. These he regarded as finer developments in treatment. The source of all problems was the insufficient number of institutions, and the fact that the few that existed were only characterised by detention, not treatment (144). Dr. Major also agreed that the country needed first more mental asylums with a large central building and separate pavilion for the raging patients, and a separate one for those who are already improving. Only after these should come family care (145). Laufenauer referred to a short treatise he wrote 24 years earlier on the overcrowdedness of mental institutions in the country, the essence of which was the proposal to establish colonies. He had “since then cured of this idea.” Until there were enough mental asylums with closed wards in the country, time was not ripe for colonies yet (145). Finally, Chyzer suggested that in his mind, the colony could be constituted of a central building and connected economic establishment and equipment, such as the Lipótmez˝ o and Angyalföld State Mental Institutes. For Chyzer, family care was out of question in Hungary, he believed, as the state only paid after patients who were dangerous to others or themselves. He ended with the idea that in case he was given money to pay for a mental institute, he would build a central building, with separate pavilions and colonies (146). The last respondent at the 1900 Congress, the Nagyszeben (and later Lipótmez˝ o) state mental asylum director, Jen˝ o Konrád sounded the most optimistic regarding these innovative approaches and also the most determined to introduce them. He agreed with Oláh that the integration of the mental asylum, the colony and the family care would be the right way to go as this would make individualised treatment possible. He proposed that the family treatment system could be introduced in his own institute in Nagyszeben with Szekler families. Konrád told his colleagues that he kept married couples as nurses in Nagyszeben who could be provided with houses and mental patients could be given out to them for care and treatment (146). Indeed, as we will see below, Konrád was the most agile and successful professional to put these ideals into practice, much sooner than others thought.

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A couple of years later, Kálmán Pándy went for a 7-week trip in 1903 to observe Scandinavian (Norway, Denmark, Sweden), Scottish, English, Dutch, Belgian, French and German systems of family care and institutions and published his findings in lengthy articles in Orvosi Hetilap, including information on the Russian and American family care systems as well.40 Although his title contained only family care, Pándy clearly included colonial treatment as well. Pándy concluded his experience that family care could be established anywhere with professional control, it did not necessitate a long tradition to work successfully (500). He argued that even patients originally admitted to institutions as dangerous to the public would soon get considerably calmer and be eventually ready for family care without posing unnecessary dangers to their environment. He claimed that—unlike Oláh saw this—the patients he witnessed in family care during his travels did not differ from the patients kept in Hungarian institutions, who could easily and successfully be given out to foster families. In fact, all sorts of patients, regardless of their age and form of mental disorder, should be considered for family care, importantly including curable patients as well! (501). What is more, many patients regarded as dangerous could also be treated in family care, as they proved to be more aggressive in closed institutions (441).41 Contrary to previously held beliefs, not only quiet and peaceful rural environments could be advantageous for family care, he continued, but also busier urban centres, given the examples of Berlin (501) or Vienna.42 Finally, Pándy warned against regarding family care as a poor policy solution. His example was Geel, where rich patients were also cared for and often successfully cured, given the advantage that a nurse could be constantly present and focusing on the patient, unlike in institutions (501). Pándy and Konrád also emphasised the “extraordinary advantages” of the system: patients’ “great happiness” over the family care which provided more freedom than institutionalisation, their better health, the small necessary investment and moderate costs of sustenance, and the alleged “happiness of the population of a small town” as well.43 Konrád similarly argued that from a professional point of view, the freer and friendlier atmosphere of family care, the familiar life style and possible activities made family care much more beneficial to the patient than hospitalisation, it had “a curing influence on the invalid psyche.”44 He also emphasised the financial advantages of family care and estimated that it was approximately one-third cheaper for the state than institutional care, not counting the capital invested in the buildings. And as it arose in many

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writings on family care, the families gained a livelihood from it as well. It seemed advantageous to all parties concerned, including the mental institutions thus relieved of incurable patients (179). The main prognosticated difficulty was finding adequate families for fostering. Konrád thought that the male or female member of a wouldbe foster family should visit a mental institution for a couple of weeks for practice, where he could receive some training and would meet the patients who would be entrusted to his/her care (184). This would also enable the head of the institution to flexibly negotiate the monthly payment after the patient, knowing how problematic each patient was. After the director had ample evidence concerning the moral, financial and lifestyle circumstances of the foster families trained at his institute, he could initiate the official procedure and sign contract with them as caretakers (185). Such an arrangement would guarantee the adequate professional and moral standards of family care. As to what proportion of inmates could be released from institutions and placed into family care, Konrád quoted foreign experts who claimed 25–33%, while the Americans estimated 50%. Konrád agreed that 50% could be achieved if families were carefully chosen (179), while Pándy optimistically estimated that 2/3 of the patient population in Hungarian mental asylums could be treated in the much cheaper colonies and family care. Regarding the possible location of colonies and family care, two connected issues were raised: what areas were ideal for the colony and family care in general and what would fit the patient the best? The first was not a simple issue in a multi-ethnic kingdom. Pándy believed that family care could “be successful everywhere, regardless of ethnographic culture.”45 Konrád was already more cautious, he suggested that family care had to be established with a great deal of flexibility: in each region paying attention to the life conditions of the people living there.46 Chyzer was more restrictive when he stated that the conditions and character of a people also had to be taken into account: “the fact that something worked in Germany, did not mean that it worked in Hungary as well.” “Our Hungarian peasant would never take in a mad for any money. Perhaps the Saxon or the Zipser German would be the most suitable for this,”47 he stated. Elsewhere he prognosticated that there were only very few regions in Hungary that would be appropriate for the system of family care: “the northern border lands are not useable, since the population there do not have adequate housing, and the proud magyars of the Great Plain do not

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take in mental patients. Perhaps we could give it a try in Székely Land (Szeklerland), in Szepes county, or with the Saxons.”48 Concerning the interests of the patient, several psychiatrists agreed that close to his or her home was the ideal: Due to ethnographic and other factors that have a deep impact on the soul and the treatment of the psyche, the closed institution, the open colony and related family care should be situated where the patients live, let’s not take them from one end of the country to the other, where they are torn from their relatives and familiar impressions, and no-one speaks their language.49

There is evidence that the state proposed a rather large amount of money (2 million crowns) for the establishment of a colony. Professionals considered whether the Belgian, Scottish, French or German, etc., system of family care would fit the Hungarian conditions the best. Pándy preferred the model he saw in Jerichow: a 100–150-bed centre with mental health care and additional 300–350 patients accommodated by families. From the large state money, he nevertheless proposed the establishment of at least four Ainay-le-Chateau-type family colony.50 Konrád regarded the Scottish system of family care the best but proposed combining it with the Alt school and the Dalldorf system.51 Several smaller institutes connected to family care would be the most beneficial, covering the large countryside regions where no institutions existed. Yet considering the always disappearing funds and resources, instead of new buildings and special centres, Konrád recommended the utilisation of existing institutions and the building of the family care system around them.52 Konrád was right, the state money remained a dream only that soon evaporated, and it was his more sober plan that eventually materialised.53 As the result of Konrád’s ceaseless lobbying and Chyzer and Gedeon Raisz’s help on the side of government, the first colony was set up in a heterofamiliar system in Dics˝ oszentmárton in Kis-Külüll˝ o county in Transylvania (today Romania) a year later, in 1905, about 80 kilometres away from the Nagyszeben State Mental Institute where Konrád was director at the time. The “centre” (centrale) of the colony was established in the country public hospital in Dics˝ oszentmárton, where eventually a mental ward was built, and the first 15 patients arrived soon. Gradually, many

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surrounding villages were connected, one that was 10 kilometres away from the centre already counted as “far.”54 In four years between 1905 and 1909, concerning the number of treated patients, the colony became the second largest “mental institute” in the country. The colony received altogether 623 patients from other institutes, out of which 447 were placed in family care, 68 stayed in the centre, and out of the remaining 108 patients, 36 were released, 12 transferred, 10 escaped, and 50 died (five died of tuberculosis, many suffering from paralysis progressiva, and many were already in very weak and bad condition when moved to the colony) during the four years.55 Patients were mostly placed in pairs at families, sometimes alone and rarely three together. Apart from the satisfaction of basic hygienic needs, each patient was provided a separate, 15–20 m2 room, with a bed and sheets, a common table, a wardrobe, a washbowl, etc. Each room had to be heatable. Families were made responsible for full care of the patients, feeding, washing, mending cloths, etc. Cloths and tobacco were provided from the centre. The chief doctor and the chief nurse examined the patients’ health: the nurse visited the families every week, the doctor visited the patients once a month. To check on patients’ feeding, they measured them monthly to see if they gained or lost weight.56 Concerning the difficulties they encountered, the chief doctor Rudolf Fabinyi emphasised the small size and crowdedness of the centrale: originally built for 60 patients and equipped for 80, the centre in 1909 housed 110–120 patients, where isolation of the calm and agitated patients was also impossible. Apart from a few escapes, two suicides, a suicide attempt, two life-threatening attacks on family carers and a few epileptic seizures in the open street, a more general problem was alcohol abuse. This mostly affected about 8–10 patients who stayed in Dics˝ oszentmárton centre where there was a pub, not those at families in the small villages in the periphery.57 Apart from these, Fabinyi concluded that somatically, the great majority of the patients improved in family care, “they gained weight, their complexion turned red and livelier, their physical power grew.” In terms of their psychic condition, the achievements were even more visible: The formerly mostly quiet, dull, sluggish patients in time turned active, agile and sociable in family care. What is more, we can also state that they become literally more reasonable. They really get used to their new environment and become not only accepted, but also loved member of

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their foster families. They fully participate in the family’s life, have their share from the work as well as the entertainments.58

If Konrad was earlier concerned about the recruitment of foster families, his fears proved to be unsubstantiated. A few months after the opening in 1905, 19 families participated in the system, four years later, already 207. The majority of carers were peasants, but there were also artisans, officials and merchant, etc., involved. Since the farmers were able to feed patients with their own farm produce, food did not cost much money, “keeping mental patients for these families (was) indeed a very profitable business.”59 It was due to this “financial benefit, which the families could earn with not too difficult work, that family care became a regular source of income in the region and the institute acquired great popularity,” thanks to which another 382 families already volunteered as carers, Fabinyi proudly stated. Even if only half of them proved to be eligible, another 360 patients could be easily placed in the current region of the care system (86), the patient population thus reaching 1000 in a couple of years. Most family carers lived up to the requirements, patients only had to be removed from about 3–4 families annually due to problems (which Fabinyi did not specify). He rather provided data to prove how financially advantageous this form of care was for the individual families as well as the region in general, which demonstrated the “enormous social benefit family care brings, in addition to the interest of the patients” (86). Costs of care suggested that it was cheaper than institutional care and advantageous to existing institutions that served as the centre. The Dics˝ oszentmárton colony was followed by a colony in Nagydisznód connected to the Nagyszeben State Mental Institute in 1906, under László Epstein’s directorship.60 By 1909, 16 families cared for 30 patients. The head of one family was entrusted with the “direct supervision” of the system by visiting all of the families once or twice a week, acting as a kind of “chief nurse.” The local doctor also visited the families once or twice a month and patients were brought to his house at the end of the month where the nurse measured and recorded their weight. There was also one or two visits per month by professionals from the Nagyszeben mental institute.61 Konrád continued to work on a national organisation of family care by establishing new colonies in Balassagyarmat (1907), Nyitra (1907), Sátoraljaújhely and Baja, which reflected a good geographic distribution

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in the country.62 In Balassagyarmat, 100 patients were cared for in 56 families by 1909,63 at the colony connected to the mental ward of the public hospital in Nyitra, 94 patients taken in by 63 families by 1909. In Sátoraljaújhely, the chief doctor of the public hospital mental ward sought permission to give work to patients in his own vineyard while also providing family care. His example was followed by others and there were already 17 patients in family care by 1909, when the deputy lieutenant (alispán, vice comes) sought permission from the Interior Ministry to establish a colony. Developments were interrupted by personal changes. In the southern regions of the country, the Baja public hospital also requested the establishment of a colony related to the public hospital in 1909 (89, 93). In most of these places, the directors reported improvement in the patients’s condition thanks to the increased freedom they experienced and to work,64 and emphasised their increased sociability and calmness. They also stressed aspects of the positive influence family care had on families and the general population, including moral as well as economic factors. Villagers were allegedly “competing with each other” and “bothering” the doctors to get patients, those that already had patients, built new rooms for them to keep them. There were improvements from a public health point of view as well: the frequent visitations by doctors resulted in clean homes where even the “daily airing” was introduced.65 Konrád concluded that family care was a success, as it “managed to improve the condition of chronic patients idly loitering and deteriorating towards full dementia in closed institutions and give them back at least partly to society” (98). But it also improved foster families’ moral and hygienic life and provided them with a living. Finally, family care was financially advantageous for the state, which thus could sustain a cheaper care for mental patients without any initial investment (because the system was mostly organised around already existing institutions) (98–99). Small Specialised Institutes for “Imbeciles” and “Idiots,” Epileptics, Alcoholics, Nervous Patients, and Criminals Therapeutic nihilism discussed in the second chapter urged psychiatrists to look for further alternatives in other types of institutions and psychiatric practices. Some argued for the establishment of small institutions specialised in different areas on the model of tuberculotic clinics66 : institutes for epileptics, “imbeciles,” “idiot children,” criminals, alcoholics,

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nervous patients, etc. These small institutes were partly designed to relieve large mental institutions of their most burdensome patients and provide special groups of the mentally ill with more tailor-made treatment, performing these functions also in a more cost-effective way. Such an institutional fragmentation that went hand in hand with specialisation was seen as beneficial for patients and advantageous for the profession in large. Revealingly, within mental health care, such specialised institutes emerged almost entirely in the private sector (except for the institute for criminal mental patients). Institutes for “Imbeciles” and “Idiots” In the mental health pharmacopoeia, ‘the institute itself’ has proved to be an efficient medicine. This excellent medication must be cleansed of all parts which produce the unpleasant side effects. This has already been partly done when criminal mental patients were removed to annex institutes by prisons or to separate institutions, now it is still necessary to eliminate the imbeciles who disturb the institute in its healing character and lower its repairing capability. But when we remove this element [imbeciles] from the mental institution, we … also do it to place these elements … into a more expedient, more appropriate milieu better fitting their ailments, and thus we achieve the still possible improvement in their condition.67

The tradition of building institutions for and thus isolating the “feebleminded,” “imbeciles,” “idiots,” and as they were more generally designated by the turn of the century, the “degenerates,” goes back to the middle of the nineteenth century in parts of Western Europe and the United States of America. From then, different child protection societies, special education institutions for children with needs and schools for feeble-minded children were established in England, Switzerland and Germany, in the name of humanitarian goals.68 In the Hungarian Kingdom, the first special education institutes were established for the deaf and dumb and the blind. The School for the Deaf and Dumb (Siketek Nevel˝ oháza) was founded in 1802 in Vác (later also called Royal National Deaf and Dumb Institute), where Antal Schwartzer, uncle of the private madhouse founder Ferenc Schwartzer, was doctor and then director for decades.69 In 1878, similar institute was opened for Israelite children in Budapest, and then thirteen more in the country by 1914. The first institute for the blind was founded in 1825 (or 1826) in Pest, the second such institute opened almost a century later, in

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1908 in Budapest, and by 1914 there were altogether 9 institutes for the blind.70 By the end of the nineteenth century, there were two types of institutes for people (especially children and youngsters) with mental deficiency: those providing care for “untrainable idiots” (about ¾ of all “idiots”) and educational institutes for the trainable.71 The first institute for “idiots” (hülyék) in Hungary was established by the freemason lodge “Work” in Rákospalota in 1875. It was then moved to Budapest by Jakab Frimm and functioned mostly as a custodial care institution, rather than one with an educational purpose, until 1896, when it was nationalised and reorganised due to the “great importance of this institute of public interest.” From that time on, it was turned into a special educational institute where only trainable “idiots” and feeble-minded between 7 and 10 years old o could be admitted.72 A similar state institute was opened in Borosjen˝ in 1904.73 As pointed out in the article on “Hülyeség” (Idiotism) of the 1998 edition of Pallas Nagy Lexikona (Pallas’s Great Lexicon), for the “untrainable idiots,” small asylums were established by Jakab Frimm in the City Park (Városliget), by the “Love” national charity society for physically and mentally deficient people in Buda, by the Hirschler sisters in Budapest and by Rezs˝ o Blum in Pels˝ oc, Gömör county.74 Blum’s institute was established in 1898 and cared for about 200 oligophrenic children whose greatly aggressive behaviour made their care in their own families impossible and who also could not be placed among adults. In September 1905, Blum’s institute began offering systematic education for epileptic and “retarded” children, both for inmates and non-residents, for poor kids for free.75 For the education of mentally deficient day-student (nonresident) children, a new educational institute was opened in 1900 in Budapest and another 5 in the countryside by 1914.76 In his talk at the First National Alienist Congress in 1900 entitled “The education of idiots in modern institutions,” Blum emphasised that idiots and imbeciles needed no medical treatment, but rather special education and occupation or work in “specially equipped institutes and with specially trained professionals.”77 Blum differentiated three categories within the larger group of “idiots” or “imbeciles.” The first group comprised those who could not walk or talk, who were “unclean,” and suffered from epileptic fits. These patients were only “educated” in how to keep oneself clean, for this, “pedantic cleanliness” was required in the institute and preferably female nurses, as “experience showed that male nurses were not able to accomplish this task” (221). In the second group, there were

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patients who were “unclean,” either suffered from epileptic fits or not, but were otherwise physically healthy. In their case, education covered: “1., cleanliness, dressing up and washing oneself 2., gesticulation and a little exercise 3., recognition of objects 4., basic concepts”

Some patients in this group were already intelligent enough to also learn reading, writing and speaking (221–222). The third group of patients comprised the “reasonable idiots,” who were clean, in some cases also had epileptic firs or were hysterical. In their case, in addition to basic education, they were train in gymnastic, music, singing, needlework and different occupations. The latter necessitated workshops, such as tailor, shoemaker, brush-maker, tinker, carpenter, etc., with the direction of reliable craftsman nurses. Training in gardening was also important. Those successful in the workshops could be sent as apprentice to craftsmen outside the institute, first only for the daytime, then eventually for good, thus giving them a living and independence to survive in society (222–223). Such specialised institutes properly equipped with tools and teaching practices and methods, Blum argued, could thus turn idiots employable and, to some extent, capable of self-preservation. Most of the above institutes emerged in the private sector. At the 1900 First National Alienist Congress, Laufenauer made several proposals for the improvement of the capital’s mental health care, including the establishment of a separate ward for “idiot children” at one of the existing closed mental institutions.78 When Laufenauer provoked Kornél Chyzer, representative of the government present at the congress, with the question of what happened in this regard, Chyzer replied that a plan and budget for the building of a pavilion for “idiot children” to house 25 boys and 25 girls at Lipótmez˝ o had been lying on the table for six years already, but there was no money (it would have cost 60.000 forints).79 The rise of the above discussed institutes, especially those providing special education to mentally deficient children and youngsters certainly demonstrate a growing sensitivity towards these conditions and proved to be progressive initiatives, yet the number of people who could benefit from these remained terribly low in the light of sheer numbers. According to the 1901 census in Hungary, there were 26,659 “idiots” in the 16.7 million (16.721574) population of the country.80 Therefore, the impact

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of non-educational, care institutions which ware capable of housing only a very small fragment of the “idiot” population should thus not be overestimated. Furthermore, in the lack of ample number of specialised institutes for “idiots”, general mental institutions still housed a large number of such patients. (This is true in spite of the fact that with the strengthening of family care and colonies, many people deemed “idiot” could be moved from state mental institutions into these alternative institutions which however mostly affected the adults and elderly, not children or youngsters.) Hence at the Third National Alienist Congress in 1904, psychiatrist and forensic medical expert Ignácz Fischer recommended to move the troublesome imbeciles into the National Observation- and Mental Hospital for Persons in Detention and Prisoners (see below), as it satisfied the asylum needs but most importantly, it provided strict discipline which Fischer regarded as necessary. But he also admitted that this institute only satisfied the function of detention, not of therapy, therefore a better solution was a large pavilion (in barrack style) for 60–80 patients at an agricultural colony, fenced off and far from its centre. They would be forced to do agricultural work and there would also be a workshop.81 The director of the National Observation- and Mental Hospital for Persons in Detention, Moravcsik agreed with the proposed removal of imbeciles as they were the “real torturing spirits” of mental institutions, yet not into his institute, as too strict and rigorous environment would “cause artificial agitation” in their “excitable nervous system” (208). Concerning treatment, Fischer suggested in a surprisingly and atypically harsh tone: ...orderly lifestyle and regular occupation, time spent in the fresh air, physical work, moral education, especially with an educationist, these can control the instincts at least to some extent, attenuate the bad predispositions. They must be treated with utmost austerity, they may even be punished. They must be occupied by all means, they are to be forced to work. They have to be educated, influence them with readings that improve the morals, provide them with lectures that benefit moral life (207).

Epileptic Institute Another specialised institution that demonstrates institutional fragmentation is the “epileptic institute” opened by István Wosinszki in Balf

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(Sopron county) in 1903. Alienists were quite vocal by the end of the century about the fact that the presence of epileptic patients within mental asylum populations proved to be highly problematic, their treatment and control the most difficult among the patients. These patients were not necessarily mentally deranged, they indeed sometimes had admirable intellectual capabilities, yet their often-aggressive behaviour and enigmatic epileptic fits and convulsions made them liable to become and remain asylum inmates. Within the institutions, their “over-sensitivity and petulance” were seen as easily turning into unexpected outbursts of physical aggression and bouts of anger that could leave the rest of the patients terrorised, the state asylum director Villibald Strobl claimed in 1911. He added that in court, epileptics represented the highest proportion among criminals convicted of serious physical assault.82 Strobl emphasised that if the epileptics were a curse to the sane population, they similarly meant an equally unbearable punishment for the mental patients who had to put up with them in institutions, where they were to blame for 90% of all physical violence. Where there is an epileptic patient, there quarrel and even physical insult are bound to happen. … Two, three epileptic patients are capable of making the institutional environment of a great number of patients unpleasant and constantly destroying order which would otherwise prevail (140).

Hence Strobl demanded that these people should be isolated and removed from mental institutions and treated instead in specialised ones (136–137). In the case of these patients, strict dietary requirements had to be fulfilled and both physical and psychic stimulus had to be toned down around them which made their treatment practically very complicated, there was hardly any other kind of patient whose illness necessitated so much attention and circumspection (139). It was therefore in the interest of the epileptic patients as well to be removed from such crowded institutions where there was not enough personnel and time for individual patients, Strobl believed (140–141). Wosinszki, director of the only epileptic institute which in 1911 offered treatment for 200 epileptic patients, similarly argued that the epileptic fits excited other mental patients to an extraordinary extent whose health conditions thus deteriorated, while the condition of the epileptic patient also worsened: “by

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spending all his time among the mentally disordered, in time the epileptic himself will intellectually degenerate.”83 Wosinszki also emphasised that in addition to medical treatment and a very strict surveillance, epileptic patients also needed “education” and had to be “constantly occupied.” He claimed that on Sundays, when patients did not do any work by way of occupying themselves, they suffered two times more fits than on days when they worked (142). At the 1900 First National Alienist Congress doctor Mór Turnowszky from Marosvásárhely complained that neither the state, nor charity organisations took steps to improve the conditions of these “most miserable of the miserable, the pitiable victims of morbus sacer.”84 Turnowszky emphasised social inequalities among those struck by this disease, namely that the life of wealthy epileptics was not at all as miserable as that of the poor, as they may receive “proper care, supervision, medical, perhaps institutional treatment, and they have no financial difficulties, do not have to fight for the daily bread” (233). As opposed to this, most poor epileptics end up exorcised from society and become “miserable beggar, … often dangerous rogue” (234). “Epileptics are not admitted to schools, to hospitals, they are outcasts in life, although they can be educated into very useful individuals,” Gyula Donáth added.85 Turnowszky was also optimistic: There is evidence, that proper care, professional treatment and occupation greatly decrease the number of fits, very often cease them for a long time and may prevent or at least delay the further development of epilepsy, the symptoms of physical and psychic decay. (234)

According to Turnowszky’s estimations, there could be 18–20.000 epileptics in the country, out of which 4–5000 could be treated by their families or in institutions, but 14–15.000 probably without any support and care (236). He thus propagated the establishment of epileptic colonies in the country on Western European models, especially praising the German Bielefeld colony (234). But there were other examples to consider as well, such as the “the Chalfont St Peter epileptic colony in England, and the Lewis epileptic colony in Manchester in England, the colony near Bridge of Weir in Scotland,” etc.86 There are signs of Hungarian initiatives to internationally coordinate endeavours of mapping epilepsy in countries and providing specialised care for them by the end of the first decade of the twentieth century

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on the model of fighting alcoholism, tuberculosis and cancer in the international arena.87 Yet due to the increasingly shrinking financial resources, by 1911 Strobl conceded that the building of new, separate institutions for epileptics was out of question. Therefore, he recommended at least the establishment of epileptic wards at the existing mental asylums, which would greatly benefit these institutions (141). Wosinszki disagreed in this respect, only completely isolated, separate and purpose-built state institution would suffice, where all the epileptics removed from mental asylums could be “treated, occupied and educated” (142). Apart from these propagations of the cause, the fact remains that there were only two private institutes that offered specialised education for (a very small number of) epileptics before the First World War: Wosinszki’s in Balf and Rezs˝ o Blum’s in Pels˝ oc (also educating “idiot children”). Institute for Alcoholics Alcoholics formed the next group of patients whose separation from general mental asylum population seemed desirable. Solving the “alcohol problem” had two equally important elements: prophylaxis (preventive measures) and the treatment of alcoholics.88 Concerning therapy, two conditions were essential: abstinence and time, together with “work, discipline, moral treatment.” These components were all available in alcoholic asylums, university assistant doctor Károly Décsi claimed (215). “The nervous system of alcoholics attacked by long-term alcohol abuse, their decreased moral and ethical feelings necessitate special, purpose-built institutes, asylums” which also help them eventually return to social life (217). But what seemed to be the most problematic part was that, for various reasons, alcoholics were discharged from general mental institutions too early just to relapse and be returned to the institute soon. The “psychic and moral treatment of alcoholics” necessitated a lot of time and attention, alcoholics also needed work therapy and physical exercise, which were only possible in specialised institution, and not in overcrowded mental asylums (215–217). Yet poor alcoholics were kept at state mental asylums and hospital wards in great numbers (see statistics in Chapter 7 and further details on the alcohol problem in psychiatry in Chapter 8), and one can infer from sanatoria adverts that more wealthy alcoholics were placed in lucrative private institutions. There also existed the Alkoholisták gyógyítóháza (Alcoholics’ asylum) maintained by the Általános Közjótékonysági Egyesület (General Charity Association) in a sanatorium in Rákospalota where alcoholics and morphinists were treated.

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This was claimed to be the only such (charity) organisation and was led by the psychiatrist and leader of the anti-alcohol movement in Hungary, Fülöp Stein as chief doctor.89 Sanatoria for Nervous Ailments The country and the capital abundant in thermal and other medicinal waters had a long tradition of bath culture, yet it is evident from the advertisement sections of contemporary dailies and weeklies, but also medical and natural science journals, that water cures were increasingly used to treat nervous disorders. By the turn of the century, a growing number of baths, health resorts, sanatoria and other private healing institutions offered their water cures together with the latest therapeutic treatments and technologies to cater for nervous patients, among others. For instance, the Budapest Almanac, Lexicon and Guide for the years 1910–1912 (F˝ ovárosi almanach, lexikon es útmutató, 1910– 1912)90 contains, within the range of a few pages, a number of relevant advertisements: Park Sanatorium in Dunaharaszti (Pest county) presents itself as “first-rate healing institution for alcoholics, morphinists and nervous patients,” with “sun and air-bath in the winter and the summer, dietetic kitchen...” (150). Dr. Batizfaly’s Sanatorium and Hydropathic Institute in Budapest appears as “familial home for nervous patients: founded in 1859 but modernised in 1908,” offering a list of familiar but also some astonishing treatments and …: “hydrotherapy, carbonated bath, electric light-bath, hot-bath. Sun-bathing. Electrotherapy (galvanic, faradic, Franklin currents). Dietetic and medical massage. Vibration and rotation massage. Gymnastics. Fattening and slimming treatments. Constant medical attendance, careful nursing, cleanliness” (151). Városmajor Sanatorium and Hydropathic Institute in Buda for internal and nervous patients (152). Dr. Glück’s Sanatorium and Hydropathic Institute in Városligeti Fasor offering massage, electrotherapy, electric light-baths, diethetic treatment, and even “Weir-Mitchell-treatment” (famous American physician who pioneered the ‘rest cure’ for neurasthenic and hysterical patients involving confinement to bed, special diet with consumption of large quantities of milk, electrotherapy and massage).

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Svábhegy Sanatorium opened in 1909, (157). Electro-magnetic healing institute in Városligeti fasor 15., in the park of the Grünwald Sanatorium, in separate pavilion, offering: “electro-magnetic treatment, arsonvalisation (the therapeutic employment of high frequency currents), four-compartment electric bath (sic!). Electric warm and hot air-shower. Electric vibration and electric air-massage. Simusoidalisvoltaisation (treatment with alternate current), intermittent continuous current, Galvanisation, Faradisation, franklinisation, X-ray, Radium drinking- and bath cures (sic!).” Patients treated at the institute suffered from: insomnia, general nervousness (neurasthenia, hysteria), neuralgias, spinal cord problems, headaches, paralysis, nervous heart disorders, stomach and bowel nervousness, nervous itching, cramp in the womb, asthma, rheuma, etc. (155). In several of these adverts it was explicitly stated that no mental patients were admitted, only nervous patients, obviously to avoid the stain of mental illness. Thus, understandably, even the Schwartzer institute was advertised in the Almanach as Sanatorium for nervous patients (by this time, the Schwartzer institute had two parts, one serving for mental illnesses and the other for nervous diseases separately.) Still echoing the founder Ferencz Schwartzer’s holistic view, his son Ottó Babarczi Schwartzer claimed to have been the “doctor of the body and the soul,” as psychiatrist, occupying an “eminent and shining position in the medical society, who is surrounded by the admiration and respect of European experts,” who “has visited all (sic!) of the institutes for nervous diseases in the world, studied them and used all the excellent experiences he gained in them in his own institute.” If this was not enough to convince patients and their families, they were informed that “strength and kindness radiate from his head. His friendly eyes induce trust in those in need of care, although with a single glance, he can penetrate into the most hidden secrets of his patients” (156). The advertisement in the Almanach writes about his persona in detail while not a single word is spared on the institute itself, which much resembles the cognitive world his father created and occupied when he established his first private mental asylum in the country in 1850 where the charismatic doctor’s role was so central and over-towering in treatment.

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Since these sanatoria catering for nervous disorders mushroomed in urban centres and mostly in the private sector, they were frequented by wealthy or upper-middle class clientele. Hence it is important that psychiatrists on the turn of the century began to demand such institutes for poor nervous patients as well, who had no means to pay for private treatment. The alienist Salgó emphasised the importance of taking patients into institutions before the onset of their ailments, or at the early stages of their mental illness. Yet he pointed out the social inequalities at work in this respect: he argued that more affluent families were more likely to bring their mentally disordered relatives into institutions earlier than poorer families, who often waited until treatment was already of secondary importance to the custodial needs. Interestingly, he referred to these patients in the early phase of their disease as “nervous patients or what you like.”91 Therefore, Salgó proposed the treatment of these early stage “nervous” patients in newly built institutions where they could be easily admitted (without the “huge apparatus necessary” for the official stating someone mentally ill and without the guardianship procedures). Patients could simply walk into these institutes on their own or be taken there by their families and be admitted like in any other hospital.92 Several doctors including Pándy, Oláh, Jakab Fischer and Epstein supported the proposition which would have meant a separation of such milder cases from the asylum population. Elsewhere Oláh argued that there was a great need for “people’s nerve-sanatoria” (“nép-idegszanatórium”), the “mighty tools in social preventive mental health care,” where great number of patients with “exhausted nervous system” could be treated. If these were located by existing mental asylums, that would not be a disadvantage to them, whereas would constitute a huge advantage for mental patients housed in asylums by “radically” improving the status of this institution with the removal of the “abhorrent asylum character.”93 Yet there is no evidence that the state moved towards funding such initiatives in the period leading up to the First World War. National Observation- and Mental Hospital for Persons in Detention and Prisoners Most of the above discussed specialised institutions emerged in the private sector, although some received state funding as well. There is one more specialised institution that needs to be taken into account: the state-founded National Observation- and Mental Hospital for Persons in

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Detention and Prisoners94 (Letartóztatottak és Elítéltek Országos Megfigyel˝o és Elmegyógyító Intézete, hereafter NOMH) established for 140 patients by the Ministry of Justice in 1894, first temporarily by one of the metropolitan prisons, then from 1896 permanently as part of the large, newly built, modern Royal National Prison (Királyi Országos Gy˝ ujt˝ ofogház), the biggest such institute in Central Europe at the time. The purpose of the institute was to relieve state asylums from forensic cases and collect arrested or convicted criminals whose mental state necessitated observation, cure or care.95 The psychiatrist who fought hard for years for the foundation and opening of the institution was Ern˝ o Moravcsik, clinical psychiatrist on the side of Laufenauer at the Department of Mental Health and Pathology and its related clinic,96 who also trained himself to become one of the leading forensic psychiatrists of the country. In his talk at the First National Alienist Congress in 1900, Moravcsik differentiated between criminals who mostly committed crime due to their unfavourable conditions and the “habitual criminals” or miscreant proper. Fitting the contemporary intellectual climate marked by degenerationist thinking, Moravcsik believed the latter to be mostly “degenerate individuals” with a predisposition to commit crimes.97 Based on his experience, he claimed that those criminals who became mentally ill after their arrest tended to come from the first group: who committed crime (with sane mind) because of their difficult circumstances (though they may also have a disposition for mental illnesses). At the same time, a great number of “habitual criminals” were already mentally ill in the first place, mostly suffering from pathological mental weakness (102). Due to the “obscurity” of the mental illness of many of these criminals, these disorders remained largely unrecognised in society and only became evident once the criminal committed crime and was brought to justice when experts uncovered the disorder (103). Such habitual criminals who ended up in asylums turned out to be the “evil spirits” of mental institutions who could disturb the peace of entire wards. They were the real troublemakers, the instigators to violent outbursts, physical assaults, escapes, conspiracies, all sorts of nuisances, and they were the source of “psychic infection, the foci of unfavourable suggestive influence and demoralising impact” whose presence was greatly problematic for convalescent or cured patients. In addition, Moravcsik emphasised, these criminal mental patients who needed more severe disciplining also made the freer treatment of regular mental patients spreading

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in institutions by the turn of the century impossible. He thus found it absolutely necessary to eliminate such criminals from asylums (105). Many voices criticised the hospitalisation of criminal mental patients, as it led to the loss of the curative capacities of these institutions and they were degraded to “detention establishments,” completely changing their character.98 According to Moravcsik, the Americans, the English, the French and Belgians supported the idea of separate but centralised larger institutions for criminal mental patients, while German professionals criticised the concentration of great number of such “corrupt elements” as greatly detrimental. Moravcsik referred to lively recent debates between German mental doctors and criminal lawyers: some did not find it necessary to institutionally separate criminals from other mental patients, while others argued rather for the psychiatric education of doctors in prisons and detention houses. Yet others imagined special, more protected wards with stricter discipline set up for criminals in normal mental asylums (104). Finally, great support surrounded the solution of separate mental wards within detention houses (“Irrenstation”), with good examples for this in Germany in Waldheim (opened in 1876) and Berlin (1888) (104). The logical answer to the question of what to do with criminal mental patients would be to place them in mental asylums due to being dangerous to the public, Moravcsik began his argument. Yet since asylums were curative institutes where physical and mental peace constituted the foundation of treatment, placing patients with violent and disruptive behaviour there was an untenable idea. The asylum population was mostly made up of “honest individuals with clean sheet,” placing them together with the “unpeaceful, violent, morally corrupt” criminal mental patients would have a detrimental effect on them. Opening the NOMH in 1894 partly solved this problem. It satisfied professional requirements for a psychiatric institute and offered space for: (1) the observation of the dubious mental state of pre-trial detainees and prisoners; (2) the treatment and nursing of prisoners and pupils of reformatories who showed signs of mental derangement or other symptoms of agitation which necessitated special treatment (for instance, frequent epileptic or hysterical fits) (105). Those in the first group were moved back to the prison after their observation was over, unless the mental condition of the person was so grave that it made the move unadvisable, in which case the person awaited the court decision at Moravcsik’s institute. Those in the second group remained in the institute for treatment until they were cured. If that

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happened before the end of their punishment, they were returned to their respective prisons. If the punishment expired and the person was still ill, he was taken to a mental asylum or placed in home treatment (depending on dangerousness).99 NOMH was furnished and equipped satisfying the requirements of an asylum, only surveillance and discipline were more rigorous. The medical director of the institute responsible for treatment, Moravcsik himself, was under the direct control of the Ministry of Justice, while the administrative duties were fulfilled by the prison director. The two directors were on equal level.100 Moravcsik urged the removal of all criminal mental patients from public asylums to his specialised institution. Based on his calculations, annually, there were approximately 40–50 pre-trial detainees in Budapest whose mental state necessitated placement in mental asylum. Concerning existing state mental asylums, in 1900, there were 72 mentally ill criminals out of the 560 male mental patients and 19 mentally ill criminals out of 487 female inmates at Lipótmez˝ o. At the Angyalföld institute, 33 criminal mental patients out of 198 male inmates and 16 criminals out of 154 female inmates. All of these and the annually newly admitted patients could be house at Moravcsik’s institute, which was designed for 140 patients but could easily house 200, yet Moravcsik also emphasised the need for another similar institution to be opened in the country in the future (designed for not more than 200–300 patients, otherwise strict discipline and surveillance as well as individualised treatment would be jeopardised) (107–108). Furthermore, Moravcsik proposed the occupation of these patients with industrial work, farming and other mechanical works, as “according to experience, such physical work advantageously influence the blood circulation of the brain, the conditions of digestion and thus also the pathological psychic state” of the patient (108). Most responses to Moravcsik’s proposal to move criminal mental patients from mental asylums to his specialised institution was warmly welcomed, since “parents and other family members do not like to know that their children and decent relatives are among murderers, prostitutes and evildoer imbeciles.”101 Chyzer however intervened that the Justice Minister would not support the move of the most troublesome criminal mental patients from asylums to the NOMH, as this institution was only for the observation and treatment of prisoners, those who went mad during their detention and for mentally ill prisoners. If a person’s judicial procedure was closed, he should be immediately removed to a

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mental asylum, Chyzer claimed, preferably in some isolation from other patients (109). Moravcsik responded that Chyzer himself had suggested this transfer of criminal mental patients to his institution when Chyzer visited it earlier. Asylums were so overcrowded that professionals should be happy to fill other “empty” institutes, such as his specialised institution (109). The idea that a distinction had to be made between mentally disordered persons who committed crime and criminals who became mentally ill after they committed crime was raised in the discussion. It was Ottó Babarczi Schwartzer, director of the Schwartzer private mental asylum who argued that these two groups should not be taken on equal standing and he thus did not find it right to have criminal mental patients from asylums be moved to an institute where there were proper criminals. On the other hand, their isolation and move together to a special institution would also stigmatise them, only poor patients would be taken to such a place, not someone from the more affluent classes. He found it to be the duty of mental asylum directors to isolate patients in a way that the dangerous did not meet the peaceful ones (109–110). Oláh regarded Babarczi Schwartzer’s comment “philanthropically justified,” but added that he would nevertheless move the “degenerate type” criminal patients from mental asylums, as otherwise these crowded institutions got easily stigmatised as “prisons” (110). Moravcsik also responded to Babarczi Schwartzer that his institution was itself a form of mental asylum and not a disciplinary institution, equipped for a better protection of the patients, therefore these criminal mental patients would be moved from the normal mental asylums to his specialised one for better treatment, not for punishment. Moravcsik also assured his colleagues that patients with a criminal record would have to be isolated from those with an unblemished past since “their suggestive influence would form a criminal character” (110).102 To conclude, since financial constraints thwarted plans of building progressive, modern mental institutions in pavilion system, many institutions were proposed as alternatives to the state mental asylum for the treatment of mental and nervous patients. These demonstrate both a disappointment with the limits of the asylum, and a specialisation and fragmentation of knowledge, which necessitated a specialisation and fragmentation in the institutional world as well. Some initiatives seem to have been rather successful and had a considerable impact on the mental health care in the country, such as family care and colonial settlements, or the

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isolation of criminal mental patients from the rest of the asylum population with “unblemished past,” or the world of sanatoria catering for nervous patients. Initiatives in other areas however did not lead to considerable institutionalisation, such as the care and education for epileptics, or ample specialised institutional care for “idiots.” It also seems, that the more successful projects were dependent rather on private money than on state funding. Where the state did invest into successful projects (such as family and colonial care), the motivation was also strongly financial: the promise of a more economical solution compared to the traditional asylum.

Notes 1. Eric J. Engstrom, Clinical Psychiatry in Imperial Germany. A History of Psychiatric Practice (Ithaca: Cornell University Press, 2003), esp. 1–51. 2. Erna Lesky, The Vienna Medical School of the 19th Century, trans. L. Williams and I.S. Levij (Baltimore and London: Johns Hopkins University Press, 1976), 339–341. 3. Ibid. 4. Ian Dowbiggin, Inheriting Madness: Professionalization and Psychiatric Knowledge in Nineteenth-Century France (Berkeley: University of California Press, 1991). 5. Ottó Babarczi Schwartzer, A Budai Magán Elme- és Ideggyógyintézet értesít˝oje (Report of the Buda Private Mental and Nervous Institute) (Budapest: Hornyánszky Viktor, 1894). 6. Although the Viennese Medical Faculty was an alternative option, the biographies of the second generation psychiatrists’ show the dominance of the Budapest Medical Faculty in this respect. 7. On general psychiatric pessimism in different European countries, see, Roy Porter, Madness. A Brief History (Oxford: Oxford University Press, 2002), 118–122; Edward Shorter, A History of Psychiatry from the Era of the Asylum to the Age of Prozac (New York: John Wiley and Sons, Inc., 1997), 46–68. 8. Jakab Salgó, Az elmekórtan tankönyve (Textbook of Mental Pathology) (Budapest: Franklin Társulat, 1890), iii–iv. 9. Salgó (1890), 3. 10. Jakab Salgó, “Az elmegyógyászat oktatásáról” (On Teaching Mental Pathology), in Az 1900. évi október 28–29-én Budapesten

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tartott Els˝o Országos Elmeorvosi Értekezlet munkálatai (Proceedings of the First National Alienist Congress, Held in Budapest, on 28–29 October 1900), ed. László Epstein (Budapest: Pallas, 1901), 85–88. 11. This criticism can also be found in Moravcsik’s account of the history in the period: see Ern˝ o Moravcsik, “A psychiatria fejl˝ odése hazánkban az utolsó 50 év alatt” (The Development of Psychiatry in Our Country During the Last 50 Years), Orvosi Hetilap (Medical Weekly) 1 (1906a), 38–42. 12. See Laufenauer’s response to Salgó in Salgó (1901), 87. 13. Villibald Strobl, “Az epilepsiások és az elmegyógyintézeteink” (Epileptics and Our Asylums), in Az 1911. évi október hó 29én és 30-án Budapesten tartott VI. Országos Elmeorvosi Értekezlet Munkálatai (Proceedings of the Sixth National Alienist Congress, Held in Budapest, on 29–30 October 1911), ed. Károly Hudovernig (Budapest: Pesti Könyvnyomda, 1912), 135. 14. Ministry of Interior, Magyarország elmebetegügye az 1900. évben (Mental Health Care in Hungary in 1900) (Budapest: Schmidl Sándor Könyvnyomdája, 1901), 4. 15. Gusztáv Oláh, “Referátum az elmebetegkezelés újabb elveir˝ ol” (Report on The Novel Principles of the Treatment of Mental Patients), in Az 1902. évi október 26-án és 27-én Budapesten tartott Második Országos Elmeorvosi Értekezlet munkálatai (Proceedings of the Second National Alienist Congress, Held in Budapest, on 26– 27 October 1902), ed. László Epstein (Budapest: Schmidl Sándor Könyvnyomdája, 1903a), 123, 126. See also Gusztáv Oláh, “A modern elmeorvoslás f˝ o törekvései” (Main Tendencies in Modern Mental Health Care), in Az 1900. évi október 28–29-én Budapesten tartott Els˝o Országos Elmeorvosi Értekezlet munkálatai (Proceedings of the First National Alienist Congress, Held in Budapest, on 28–29 October 1900), ed. László Epstein (Budapest: Pallas, 1901a), 121–127. 16. Károly Lechner, “Az elmebetegkezelés és újabb elvei” (The Novel Principles of the Treatment of Mental Patients)., in Az 1902. évi október 26-án és 27-én Budapesten tartott Második Országos Elmeorvosi Értekezlet munkálatai (Proceedings of the Second National Alienist Congress, Held in Budapest, on 26–27 October 1902), ed. László Epstein (Budapest: Schmidl Sándor Könyvnyomdája, 1903), 109.

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17. For criticism of mental asylums and ideas for improvement, also see László Epstein, “A tébolyda mint elmegyógyintézet” (The Asylum as Mental Institution), in Az 1900. évi október 28–29-én Budapesten tartott Els˝o Országos Elmeorvosi Értekezlet munkálatai (Proceedings of the First National Alienist Congress, Held in Budapest, on 28–29 October 1900), ed. László Epstein (Budapest: Pallas, 1901b), 155–164. 18. On these institutions, see Leslie Topp, Freedom and the Cage. Modern Architecture and Psychiatry in Central Europe, 1890– 1914 (The Pennsylvania State University Press, Pennsylvania, 2017). For Steinhof, see Leslie Topp, “Otto Wagner and the Steinhof Psychiatric Hospital: Architecture as Misunderstanding,” The Art Bulletin 87, no. 1 (March, 2005), 130–156. 19. Ministry of Interior (1901), 5–8. 20. Pándy worked at the mental ward of the Gyula County Hospital (1899–1905), then moved to work at Lipótmez˝ o as head ward doctor, and in 1911 he became the director of Nagyszeben State Mental Institution until 1919. See János Iványi, “Pándy Kálmán erdélyi évei” (Kálmán Pándy’s years in Transylvania), Orvosi Hetilap (Medical Weekly), 1–4 (2006), 87–89. 21. Kálmán Pándy, “Az elmebetegápolás jobb és olcsóbb rendszereinek megvalósításáról Magyarországon” (The Establishment of Better and Cheaper Systems of Mental Health Care in Hungary), in Az 1900. évi október 28–29-én Budapesten tartott Els˝o Országos Elmeorvosi Értekezlet munkálatai (Proceedings of the First National Alienist Congress, Held in Budapest, on 28– 29 October 1900), ed. László Epstein (Budapest: Pallas, 1901), 193–213; 194. Kálmán Pándy, Gondoskodás az elmebetegekr˝ol más államokban és nálunk (The Care for Mental Patients Abroad and in Our Country) (Gyula: Corvina, 1905), 384. See also Strobl (1912), 135. Part of the same criticism also appears in László Epstein, “A lipótmezei állami elmegyógyintézet szerepe a magyar elmegyógyászat fejl˝ odésében” (The Role of Lipótmez˝ o State Mental Institution in the Development of Hungarian Psychiatry). Gyógyászat (Medicine) 27 (1922), 401. 22. Pándy (1901), 195. 23. For criticism of the Gyula mental ward, see Károly Décsi “Az elmegyógyító osztály jöv˝ ojér˝ ol” (On the Future of the Mental

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Ward). Békés. Társadalmi és Közgazdászati Hetilap (Békés. Social and Economic Weekly), September 16, 1906, 1–3. 24. Ignácz Mandel, “A közkórházi elmeosztályok ügye” (The State of Public Hospital Mental Wards), in Az 1911. évi október hó 29én és 30-án Budapesten tartott VI. Országos Elmeorvosi Értekezlet Munkálatai (Proceedings of the Sixth National Alienist Congress, Held in Budapest, on 29–30 October 1911), ed. Károly Hudovernig (Budapest: Pesti Könyvnyomda, 1912), 213. See also Mózes Hegyi, “Az elmebetegek elhelyezésér˝ ol” (On the Allocation of Mental Patients), in Az 1911. évi október hó 29-én és 30-án Budapesten tartott VI. Országos Elmeorvosi Értekezlet Munkálatai (Proceedings of the Sixth National Alienist Congress, Held in Budapest, on 29–30 October 1911), ed. Károly Hudovernig (Budapest: Pesti Könyvnyomda, 1912), 247–250. 25. Ödön Blum, “A házi és községi ápolásról” (On Home and Community Care), in Az 1900. évi október 28–29-én Budapesten tartott Els˝o Országos Elmeorvosi Értekezlet munkálatai (Proceedings of the First National Psychiatric Congress, Held in Budapest, on 28–29 October 1900), ed. László Epstein (Budapest: Pallas, 1901), 147. 26. Ödön Blum (1901), 147. For similar criticism, see Chyzer’s response to Laufenauer in Károly Laufenauer, “Budapest székes f˝ ováros elmebetegügye” (Mental Health Care of Budapest), in Az 1900. évi október 28–29-én Budapesten tartott Els˝o Országos Elmeorvosi Értekezlet munkálatai (Proceedings of the First National Alienist Congress, Held in Budapest, on 28–29 October 1900), ed. László Epstein (Budapest: Pallas, 1901), 140. 27. Ödön Blum (1901), 150–151. 28. Jen˝ o Konrád, “Az elmebetegek családi ápolási rendszerének meghonosítása Magyarországon” (The Establishment of Family Care System for Mental Patients in Hungary), in Az 1904. évi október 23-án és 24-én Budapesten tartott Harmadik Országos Elmeorvosi Értekezlet munkálatai (Proceedings of the Third National Alienist Congress, Held in Budapest, on 23–24 October 1904), ed. László Epstein (Budapest: Schmidl Sándor Könyvnyomdája, 1905), 188. 29. Konrád’s response to Laufenauer in Laufenauer (1901), 137– 138. 30. Konrád (1905), 177.

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31. Ödön Blum (1901), 147–155; Gusztáv Oláh, “Az elmebetegek coloniális elhelyezése mellett és ellen” (On the Treatment of Mental Patients in Colonies: Pro and Contra), in Az 1900. évi október 28–29-én Budapesten tartott Els˝o Országos Elmeorvosi Értekezlet munkálatai (Proceedings of the First National Alienist Congress, Held in Budapest, on 28–29 October 1900), ed. László Epstein (Budapest: Pallas, 1901b), 143–147; Gyula Donáth, “Indítvány epilepsiás coloniák-at illet˝ oleg” (Proposal Concerning Epileptic Colonies), in Az 1900. évi október 28–29-én Budapesten tartott Els˝o Országos Elmeorvosi Értekezlet munkálatai (Proceedings of the First National Alienist Congress, Held in Budapest, on 28–29 October 1900), ed. László Epstein (Budapest: Pallas, 1901), 241–43. 32. On the different systems of family care and colonies, see Rudolf Fabinyi, “Az elmebetegek családi ápolása Dics˝ oszentmártonban” (Family Care of the Mentally Ill in Dics˝ oszentmárton), in Az 1906. évi október hó 19-én és 20-án Budapesten tartott negyedik országos elmeorvosi értekezlet munkálatai (Proceedings of the Fourth National Alienist Congress, Held in Budapest, on 19–20 October 1906), ed. Károly Hudovernig (Budapest: Pesti Könyvnyomda 1907), 68–69. Kálmán Pándy, “Az elmebajosok családi ápolása” (Family Care of the Mentally Ill), Orvosi Hetilap (Medical Weekly), 48 no. 29 (1904): 426–427; no. 30: 440–442; no. 31: 455–457; no. 32: 467–470; no. 33: 483–486; no. 34: 499–502. Konrád (1905), 176–194. On an Austrian parallel, see Leslie Topp and Sabine Wieber, “Architecture, Psychiatry, and Lebensreform at an Agricultural Colony of the Insane—Lower Austria, 1903,” Central Europe 7, no. 2 (November 2009), 125–149. 33. Pándy (1904), 501. 34. Károly Laufenauer, Az elmegyógyintézetek túltömöttsége, annak okai és elhárításáról (On the Overcrowdedness of Mental Asylums, Its Causes and Prevention) (Budapest: Franklin Társulat Nyomdája, 1875); Pándy (1904), 500. 35. They also made a long European round-trip visiting different institutions on state money in 1890, see Epstein (1922), 400. 36. Chyzer and Niedermann quoted in Pándy (1901), 193–213, 205. See their original publication: Gyula Niedermann, and Kornél Chyzer, Elmebetegügy, iszákosok menedékhelyei, és védekezés

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a tüd˝ovész ellen (Mental Health Care, Asylums for Alcoholics, and the Fight Against Tuberculosis) (Budapest: Magyar Királyi Belügyminisztérium, 1897). 37. Oláh (1901b), 143. 38. Epstein (1901b), 158. To this end, Epstein even suggested the establishment of nerve clinics at mental asylums to make them more acceptable. 39. Oláh (1901b), 144. 40. Pándy (1904). The trip was paid by Békésvármegye (Békés county) public county hospital where Pándy worked at the mental ward between 1899 and 1905. 41. Konrád also agreed with this, see Konrád (1905), 179. 42. In the debate after Konrád’s presentation in 1900, Oláh also emphasised that family care could not only be organised in “good and nice environment”, cultural centers keep their patients close by, since patients may “desire the workshop, rather than the field”. There are more patients in family care in the center in Berlin and Vienna than in the surrounding regions, he claimed. See: Konrád (1905), 190–191. In Berlin, 380 patients were in family care in the city, more than in the whole country together. See: Pándy’s response to Konrád in Konrád (1905), 193. 43. Pándy (1901), 206. For similar arguments, see also Ödön Blum (1901), 150. 44. Konrád (1905), 178 45. Pándy (1904), 501. 46. Konrád (1905), 184. 47. Chzyer in the debate after: Oláh (1901b), 145. 48. Chzyer in the debate after Konrád’s presentation in Konrád (1905), 194. 49. Pándy (1904), 484. 50. Pándy (1904), 501–502; Konrád (1905), 182. 51. On the German pioneer, Konrad Alt’s initiative at Uchtspringe mental hospital, his dynamic system of family care introduced in 1894, as well as other German, French and Belgian initiatives in family care and colonies, see Thomas Mueller, “Re-opening a Closed File of the History of Psychiatry: Open Care and Its Historiograpy in Belgium, France and Germany, c.1880–1980,” in Transnational Psychiatries: Social and Cultural Histories of Psychiatry in Comparative Perspective, c.1800–2000, ed. Ernst

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Waltraud & Thomas Mueller (Newcastle upon Tyne: Cambridge Scholars Publishing, 2010), 189. 52. Konrád (1905), 182–184. 53. Konrád planned to establish first a small village colony with family care with Szekler nursing families on the allotment adjacent to the mental institute. For lack of funding, he did not succeed. Jen˝ o Konrád, “Az elmebetegek családi ápolása Magyarországon” (Family Care of the Mentally Ill in Hungary), in Az 1909. évi augusztus hó 28-án Budapesten tartott Ötödik Országos Elmeorvosi Értekezlet munkálatai (Proceedings of the Fifth National Alienist Congress, Held in Budapest, on 28 August 1909), ed. Károly Hudovernig (Budapest: Pesti Könyvnyomda, 1910), 79. 54. Konrád (1910), 78–80; Fabinyi (1907), 67–69; Fabinyi quoted in Konrád (1910), 82. 55. Fabinyi quoted in Konrád (1910), 82–83. 56. Fabinyi (1907), 70–71. 57. Fabinyi quoted in Konrád (1910), 83–84. 58. Inid., 84. See also Fabinyi (1907), 73. 59. Fabinyi quoted in Konrád (1910), 85. 60. See Epstein (1922); Tivadar Forbáth, Adatok a magyar szegényügy rendezéséhez (Data Concerning the Organisation of Poor Relief) (Budapest: Márkus Samu Könyvnyomdája, 1908), 90; Konrád (1910), 88. 61. Konrád (1910), 88–89. 62. Epstein (1922), 418. 63. Out of the 56 families, 22 were farmers, 19 iparos, 12 policeman, railway worker and servant, and three from the more educated class. Konrád (1910), 89. 64. A great majority of the patients were occupied with work, in Dics˝ oszentmárton, two-thirds, see Fabinyi quoted in Konrád (1910), 84. 65. Konrád (1910), 91. 66. Niedermann & Chyzer (1897). 67. Ignácz Fischer, “Az imbecillek intézeti elhelyezése és kezelése” (The Institutionalization and Treatment of Imbeciles), in Az 1904. évi október 23-án és 24-én Budapesten tartott Harmadik Országos Elmeorvosi Értekezlet munkálatai (Proceedings of the Third National Alienist Congress, Held in Budapest, on 23–24

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October 1904), ed. László Epstein (Budapest: Schmidl Sándor Könyvnyomdája, 1905), 205. 68. See Ferencz Finkey, “Milyen eredménnyel jártak az Angliában és az Egyesült Államokban degeneráltak részére nyitott telepek?” (What Were the Achievements of the Colonies for the Mentally Ill in England and the United States of America?), in Az 1911. évi október hó 29-én és 30-án Budapesten tartott VI. Országos Elmeorvosi Értekezlet Munkálatai (Proceedings of the Sixth National Alienist Congress, Held in Budapest, on 29–30 October 1911), ed. Károly Hudovernig (Budapest: Pesti Könyvnyomda, 1912), 120– 127. See also Hugó Lukács, “Az idióták és imbecillisek védelme” (The Defence of Idiots and Imbeciles), in Az 1900. évi október 28–29-én Budapesten tartott Els˝o Országos Elmeorvosi Értekezlet munkálatai (Proceedings of the First National Alienist Congress, Held in Budapest, on 28–29 October 1900), ed. László Epstein (Budapest: Pallas, 1901), 224–232. 69. See A. Szabó Gordosné, “Schwartzer Antal és Károly gyógypedagógiai tevékenysége” (The Activities of Antal and Károly Schwartzer in the Field of Special Education). Gyógypedagógiai Szemle (Special Education Review) 4 (1979), 287–94; Nándor Horánszky, A Schwartzer-család a magyar tudományos életben. Bibliográfia (The Schwartzer Family in Hungarian Scientific Life: Bibliography) (Budapest: Plantin Kiadó, 2000), 6–8. 70. Lajos Lakatos, “A magyar gyógypedagógiai intézetek” (The Hungarian Institutes for Special Education) Néptanítók Lapja (Journal of the Teachers of the Populace) 29 (1909): 17–18; György Kádas, “A szellemi fogyatékosok nevel˝ o-oktatásának megoldása” (The Solution of Education for the Mentally Deficient) Néptanítók Lapja (Journal of the Teachers of the Populace) 24 (1939), 978. 71. Mór Kende, “A gyöngeelméj˝ uekr˝ ol és hülyékr˝ ol való gondoskodás Európa különböz˝ o államaiban” (Taking Care of Imbeciles and Idiots in Various States of Europe), in Az 1902. évi október 26-án és 27-én Budapesten tartott Második Országos Elmeorvosi Értekezlet munkálatai (Proceedings of the Second National Alienist Congress, Held in Budapest, on 26–27 October 1902), ed. László Epstein (Budapest: Schmidl Sándor Könyvnyomdája, 1903), 235.

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72. “Melléklet a ‘F˝ ovárosi Közlöny’ 1897-ik évi 104-ik számához” (Annex to the 1897, Number 104th Issue of the Bulletin of the Capital), F˝ovárosi Közlöny (Bulletin of the Capital) 104 (1897), 5. 73. Kádas (1939), 978. 74. See also: Lakatos (1909), 17–18. 75. Budapesti Hírlap (Budapest News), “Eskórosok oktatása” (Educating Those Afflicted with the Falling Sickness). September 22, 1905, 8. 76. Kádas (1939), 978. 77. Rezs˝ o Blum, “A hülyék nevelése modern intézetekben” (The Education of Idiots in Modern Institutions), in Az 1900. évi október 28–29-én Budapesten tartott Els˝o Országos Elmeorvosi Értekezlet munkálatai (Proceedings of the First National Alienist Congress, Held in Budapest, on 28–29 October 1900), ed. László Epstein (Budapest: Pallas, 1901), 221. 78. Laufenauer (1901), 137. 79. Chyzer’s response to Laufenauer in Laufenauer (1901), 142. 80. Data is provided by the director and chief physician of the Ungvár public hospital, Endre Novák at the 1904 Third National Alienist Congress, see Endre Novák, “Az elmebetegek ellátása a vidéki közkórházakhoz kapcsolandó elmekóros osztályokban,” (Care for Mental Patients in Annex Mental Wards Attached to Public Hospitals in the Countryside), in Az 1904. évi október 23-án és 24-én Budapesten tartott Harmadik Országos Elmeorvosi Értekezlet munkálatai (Proceedings of the Third National Alienist Congress, Held in Budapest, on 23–24 October 1904), ed. László Epstein (Budapest: Schmidl Sándor Könyvnyomdája, 1905), 221. Laufenauer provided data based on the 1880 census and claimed that there were 18,658 “idiots and cretins” in the Hungarian Kingdom. Károly Laufenauer, “Irodalom” (Literature), Orvosi Hetilap (Medical Weekly) 12 (1882b), 116. 81. Fischer (1905), 206–207. 82. Strobl (1912), 136. 83. Wosinszki’s response to Strobl’s lecture, see Strobl (1912), 142. 84. Mór Turnowszky, “Epilepsiások coloniáiról” (On Epileptic Colonies), in Az 1900. évi október 28–29-én Budapesten tartott Els˝o Országos Elmeorvosi Értekezlet munkálatai (Proceedings of

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the First National Alienist Congress, Held in Budapest, on 28–29 October 1900), ed. László Epstein (Budapest: Pallas, 1901), 232. 85. Gyula Donáth’s response to Turnowszky in Turnowszky (1901), 238. 86. Konrád (1905), 189. 87. At an international medical congress held in Budapest in September 1909, Gyula Donáth and a German colleague proposed the international study and fight against epilepsy on the model of fighting alcoholism, tuberculosis and cancer. Hence, an international league was formed with many national members. Ern˝ o Moravcsik and Donáth became members of the international organisation and the next meeting of the league was planned for the following year in Berlin to be held together with the Mental Health Care Congress. The working plans of the league prepared partly by Donáth covered: the statistical mapping of all epileptic patients in the countries and their proportions within the population, what type of institutions existed for their care, what forms of treatment were introduced, etc. The Hungarian national committee was formed by Donáth, Moravcsik, Konrád, Fischer, Sarbó, among others. See Ignácz Fisher, “Az epilepsia ellen való védekezésre alakult nemzetközi liga m˝ uködésér˝ ol, különös tekintettel a liga magyar bizottságának munkálkodására” (On the Activities of the International League for the Defence against Epilepsy, with Special Regard to the League’s Hungarian Division), Orvosi Hetilap (Medical Weekly) 6 (1911), 90. 88. Károly Décsi, “Az alcoholisták intézeti elhelyezésér˝ ol” (On the Institutional Care of Alcoholics), in Az 1900. évi október 28–29-én Budapesten tartott Els˝o Országos Elmeorvosi Értekezlet munkálatai (Proceedings of the First National Alienist Congress, Held in Budapest, on 28–29 October 1900), ed. László Epstein (Budapest: Pallas, 1901), 214. 89. For private sanatoria, see adverts in Orvosi Hetilap (Medical Weekly) from the turn of the century or the section below here. For the charity institute, see “Vegyes hírek” (Miscellaneous News), Orvosi Hetilap (Medical Weekly) 39 (1910), 700. 90. Imre Gúthi, ed., F˝ovárosi almanach, lexikon és útmutató. 1910– 1912 (Yearbook, Lexicon and Guide to the Capital. 1910–1912) (Budapest: Légrády testvérek, 1912), 148–49. For an Austrian

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example, see Leslie Topp, “An Architecture for Modern Nerves: Josef Hoffmann’s Purkersdorf Sanatorium,” The Journal of the Society of Architectural Historians 56, no. 4 (December 1997), 414–437. 91. Jakab Salgó, “Szegénysorsú idegbetegek intézeti kezelésér˝ ol” (On the Institutional Care of Nervous Patients from a Poor Background), in Az 1904. évi október 23-án és 24-én Budapesten tartott Harmadik Országos Elmeorvosi Értekezlet munkálatai (Proceedings of the Third National Alienist Congress, Held in Budapest, on 23–24 October 1904), ed. László Epstein (Budapest: Schmidl Sándor Könyvnyomdája, 1905b), 169–176, 171. 92. Salgó (1905b), 171. 93. Gusztáv Oláh, Az elmebetegségek orvoslása (The Cure for Mental Illnesses). Budapest, Pfeifer Ferdinand, 1903b, 61–62. Epstein proposed exactly the same as Oláh, see László Epstein, “Az elmebetegség veszedelme és az ellene való védekezések” (The Danger of Mental Illness and the Ways of Countering It). Orvosi Hetilap (Medical Weekly) 39 (1899), 473; 40 (1899), 486; 41 (1899), 499–500; 42 (1899), 513; esp. 513. 94. Today it is called the Forensic Psychiatric and Mental Institution (Igazságügyi Megfigyel˝ o és Elmegyógyító Intézet) in the 10th district of Budapest. 95. See 1895 No. 7,020 decree issued by the Minister of Justice concerning the establishment of the National Observation- and Mental Hospital for Persons in Detention and Prisoners, in Kornél Chyzer, ed., Az egészségügyre vontakozó törvények és rendeletek gy˝ ujteménye. 1895–1900 (Collection of Laws and Decrees Concerning Health Care. 1895–1900) (Budapest: Dobrowsky és Franke, 1900), 109–110; Ern˝ o Moravcsik, “A b˝ untettes elmebetegek elhelyezése és ápolása” (The Placement and Care for Criminal Mental Patients), in Az 1900. évi október 28–29-én Budapesten tartott Els˝o Országos Elmeorvosi Értekezlet munkálatai (Proceedings of the First National Alienist Congress, Held in Budapest, on 28–29 October 1900), ed. László Epstein (Budapest: Pallas, 1901), 100–111. 96. For more on Moravcsik, see Chapter 5.

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97. See Moravcsik (1901), 102. See also Ern˝ o Moravcsik, “A degeneratív tünetek jelent˝ osége a b˝ unösségi hajlamnál” (The Importance of Degenerative Signs in Criminal Dispositions), Orvosi Hetilap (Medical Weekly) 2 (1891), 13–17. 98. See, for instance, Ödön Blum (1901), 149–150. 99. Ern˝ o Moravcsik, “B˝ untettes elmebetegek elhelyezése” (The Placement of Criminal Mental Patients), in Az 1902. évi október 26-án és 27-én Budapesten tartott Második Országos Elmeorvosi Értekezlet munkálatai (Proceedings of the Second National Alienist Congress, Held in Budapest, on 26–27 October 1902), ed. László Epstein (Budapest: Schmidl Sándor Könyvnyomdája, 1903), 135–136. 100. Moravcsik (1901), 106. 101. Oláh’s response to Moravcsik (1901), 108–109. 102. The same question of how to treat these two types of mentally disordered criminals was raised by Moravcsik at the next, Second National Alienist Congress in 1902, see Ern˝ o Moravcsik, “B˝ untettes elmebetegek elhelyezése” (The Placement of Criminal Mental Patients), in Az 1902. évi október 26-án és 27én Budapesten tartott Második Országos Elmeorvosi Értekezlet munkálatai (Proceedings of the Second National Alienist Congress, Held in Budapest, on 26–27 October 1902), ed. László Epstein (Budapest: Schmidl Sándor Könyvnyomdája, 1903), 129–139.

CHAPTER 7

Asylum Statistics and the Psycho-Social Reality of the Hungarian Kingdom

This chapter explores the grounds on which psychiatrists could legitimately build and spread their social criticism. It demonstrates how asylums were scaled-down images of society by reconstructing the patient populations of three major mental asylums liable to use public services of mental care between 1850 and 1915, relying on published statistics and the author’s original survey of patient files. The analysis of the social parameters of the inmate population (including gender, age at the time of admission, marital status, religious affiliation, social and professional status),1 and the pathological categories assigned to them (distribution by various mental illnesses) reflects the Kingdom’s social and cultural diversity and complexity, however distorted it was in revealing ways by social, class and gender inequalities. They also demonstrate how social problems affected mental health and hence legitimated new professional responses, going much beyond former professional concerns and allowing psychiatrists to pose as expert actors in the public space, including the authorisation to produce strong social criticism. It also allows a critical reassessment of several claims prevalent in both late-nineteenth-century psychiatric literature and recent historiography of psychiatry. These include, among others: the argument that madness became a “female malady”in both cultural representation and psychiatric institutional reality; the alleged “enormous” influence, widespread © The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 E. Lafferton, Hungarian Psychiatry, Society and Politics in the Long Nineteenth Century, Mental Health in Historical Perspective, https://doi.org/10.1007/978-3-030-85706-6_7

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in nineteenth-century psychiatric texts, of female reproductive functions and biological processes on the mental state; and fin-de-siécle medical assumptions about “Jewish nervousness.” My aim is not to take side in the often-heated debates in the history of psychiatry over thebiological versus social basis of mental illness. That would also be contrary to nineteenthcentury medical and psychiatric views which paid due attention to the intricate relationship between social and biological factors in the aetiology of mental disorders.2 Rather, I wish to demonstrate that the available rich sources of institutional statistics do not support any of the above cited nineteenth-century claims about “biology” or certain social interpretations of gender difference in late-nineteenth-century society. What I suggest instead is that the complex analysis of sociological parameters of the mental patient population underlines the differences of the degree of “modernisation” and “medicalisation” among various social groups. As we have seen in Chapter 4, the Lipótmez˝ o Royal National Lunatic Asylum in Buda, opened just a year after the 1867 Compromise between Hungary and Austria, became a symbol of national independence and civilised statehood and a pledge for the development in mental health care in Hungary. Such an enthusiasm was understandable in terms of contemporary expectations. On the one hand, as part of the nation-building process, unprecedented state investments were consented in medical and psychiatric institutions, large public lunatic asylums and hospital psychiatric wards, reflecting a new stress on “national science.” On the other hand, the establishment of Lipótmez˝ o had been long awaited. In the entire Hungarian Kingdom, there were only two mental asylums before 1868: Ferencz Schwartzer’s small private establishment in the capital and a public institution inTransylvania (South-Eastern Hungary), the Royal National Lunatic Asylum in Nagyszeben (opened with 200 beds in 1863 and serving mostly for the local population). As I discuss in detail in Chapters 2 and 4, this initial enthusiasm overpublic asylum building gradually evaporated in the subsequent decades. As in western countries, by the end of the nineteenth century most mental asylums demonstrated the inadequacies of the therapeutic asylum in which so much hope had been invested. These institutions grew overcrowded with hopeless patients and death rates were very high. While proponents of the therapeutic asylum originally emphasised individual treatment and a concern for the entire “mental personality” of the patient, asylums by this time could not cope with the flow of paralytics and alcoholics. The large numbers made personal therapy impossible.

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While lobbying for further asylums continued well beyond the turn of the century in Hungary, increasing disappointment encouraged psychiatrists to look for alternatives in other types of institutions3 and psychiatric practices.4 This internal professional criticism was certainly complemented with unfavourable judgements on asylum life and abuses by government health care officials and various social commentators. The critique, however, does not seem to have grown into a massive social movement as it did in German lands. A potential explanation for this may derive from a specific condition of Hungarian psychiatric development, namely the very low scale of psychiatric institutionalisation compared to Western European countries. Only a small portion of the population considered mentally o asylum ill5 could be treated in mental institution. Before the Lipótmez˝ was opened in 1868, only about 500–600 beds were available for mental patients in Hungary.6 During the following 35 years, the number of beds grew by almost 12 times. By 1903, almost 6,000 mental patients were cared for in institutions.7 In comparison with Western countries, this still meant a very smallscale provision of institutional care for the insane. In Hungary in 1900, only slightly more people were held in specialised mental institutions than in England a century before, although by this time the population was 1.7 times larger than that of England in 1800.8 Around 1900 when Hungary had 6,000 beds for mental patients, England had about 100,0009 ; in the 168 German public institutions, there were 94,425 mental patients, and in 128 Italian institutions, 34,802.10 The ratio of confined mental patients in the population was also much lower than in these Western countries in the years after 1900. In 1911, there was one psychiatric inpatient for every 500 population in Germany,11 and in 1909, one for 270 in England.12 Compared to these, one mental patient was hospitalised in psychiatric institutions for every 2,805 population in Hungary.13 This relative scarcity of mental patients in institutions (and the small number of such institutions) may have made abuses and inadequacies in this field far less visible and problematic for the public than in other countries. By 1900, four public state mental asylums existed in the country. Built inTransylvania, Nagyszeben asylum (with 200 beds and opened in 1863) had a special patient population recruited from that region, while Lipótmez˝ o (1868) served a national function, with a shifting proportion between patients from the capital and those from the country. While only curable and dangerous patients were supposed to be admitted to

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Lipótmez˝ o, it hosted numerous incurables as well, even though most of the latter were transferred after a while to Eger Hospital of the Hospitaller Order, which turned into a dumping ward for the most hopeless cases. To rid Lipótmez˝ o of incurables, a thirdpublic asylum was built in Angyalföld (Budapest) in 1884, with 254 beds. Originally Angyalföld was to admit only incurable and dangerous mental patients, but in practice it also admitted curable ones.14 To ease overcrowdedness, the Hungarian government provided 300 more beds for mental patients by turning the old county hall of Szabolcs county in Nagykálló into a fourth public asylum in 1896. Compared to other national asylums in Europe, their Hungarian counterparts emerged as rather unique regarding their clientele. Their recruitment drew patients from all over the country, that is, from the whole of contemporary multi-ethnic society (complete with some 13 ethnic minorities). Hungary was distinctly marked among contemporary nation states by the exceptional absence of an ethnic or a denominational majority (an ethnic or denominational group that exceeded 50% of the entire population). Indeed the Magyars, the parent population of the titular national elite, or the Roman Catholics, members of a church having functioned erstwhile as the state religion, represented less than one half of Hungary’s rank and file population at the beginning of the Dualist period. From the early Middle Ages, many ethnic groups lived within the boundaries of the Hungarian state. Due to the dramatic decrease of the Magyar population under the Turkish occupation from the middle of the sixteenth to the end of the seventeenth centuries, as well as to the subsequent settlement of different peoples after the expulsion of the Ottomans, the multi-ethnic character of the Hungarian population became even more explicit. The proportion of Magyar speakers in the population hardly exceeded 40% in 1850 and was still only around 45% in 1880.15 Due to different factors,16 the ethnic proportion changed to the advantage of the Magyars in the next decades. By 1900, 51.4%, by 1910, 54.4% of Hungary’s population (excluding Croatia-Slavonia) declared Magyar mother tongue at censuses, expressing an inextricable mix of linguistic competence and “national loyalty.”17 In this first decade of the twentieth century, the next largest ethnic groups were Romanians (above 16.0%), Germans (some 14–15%) and Slovaks (around 11.0%), Croats and Serbs

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(altogether 3.6%), Ruthenians (2.5%) as well as other minor clusters (like Slovenes and Gypsies, etc.).18 The geographic distribution of these populations was extremely diversified: there was a Romanian majority in historicalTransylvania and a Slovak majority in Upper Hungary, the Germans divided in various regional clusters, while the Ruthenians remained largely concentrated in Sub-Carpathia, the Serbs in the south and the Croats along the south-western borders.19 The denominational constitution of the Hungarian population shows a similar heterogeneity. For centuries, the RomanCatholic Church functioned as the state religion (given their religious affiliation with the ruling Habsburg dynasty). The proportion of Roman Catholics in the country around 1900 amounted only to 48.7%, the rest being dispersed among Greek Catholics (10.9%),Greek Orthodox (13.1%), Calvinists (14.4%), Lutherans (7.5%) and Jews (4.9%).20 There were clear correlations between religious affiliation, ethnicity and geographic distribution.21 The patient population of largepublic asylums demonstrate a similar complexity in terms of ethnicity, religion, culture, language and even related socio-professional status. An analysis of evidence concerning the social background of patients in comparison with basic demographic data and vital statistics also contributes to the interpretation of gender related differences in the occurrence of various mental disorders as they were identified by contemporary doctors. An important and interesting fact needs to be pointed out here. Turnof-the-century Hungarian psychiatry seems to have displayed a certain “blindness” for ethnic differences. For instance, it usually rejected to recognise any potential influence of ethnic background on the mental state. No psychiatric textbook or article published in any of the official forums discuss ethnicity as a predisposing factor in mental disorders (perhaps except forTay-Sachs-Schaffer disease among Ashkenazi Jews in the early 1900s, discussed in Chapter 5.). The same neglect of the ethnic origin is also manifest in the administrative management of large public lunatic asylums, where every conceivable social and medical parameters of the patients were recorded at the time of admission, except ethnicity. A patient’s ethnic identity of course could be deduced from his name, the language spoken or a combination of regional origin and religious affiliation. But the ethnic background itself was not explicitly registered, hence it did not provide official data on ethnic proportions in institutional populations. The reason may have been political. While denying the psychiatric and medical implications of ethnic difference, such an approach also

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prevented the biologisation or “naturalisation” of ethnic difference in racial terms conducive to racist biological discourse liable to involve ideas of racial hierarchy and exclusion. Evidence from Hungarian physical anthropology and ethnography similarly proves that these sciences served the integrative function of historical assimilation rather than fulfilling a divisive strategy in ethnic differentiation.22 As to the socially selective Schwartzer institution, the primary data originates with the director’s report published in 1864.23 In case of Nagyszeben, marked by its heavily regional recruitment inTransylvania, all data derives from seven rather detailed tables published inKálmán o, Pándy’s book on the history of the asylum in 1914.24 For Lipótmez˝ the main information is based on an original survey in old asylum files kept at Lipótmez˝ o at the time of the research conducted (since then, the institution has been closed and the files taken to a place unknown to the author). A systematic compilation (which necessitated the manual separation and subsequent chronological sorting of the more than 7,000 nineteenth-century case histories) was made on almost 3,000 (out of the total 7,000) female asylum files between 1868 and 1915, and a couple o is compleof hundred male files.25 My own survey results in Lipótmez˝ mented with data offered in a statistical overview of Lipótmez˝ o’s patient admissions and discharges during its first 40-year period from 1868 to 1908 in 1909 study by István Hollós.26 With all this, one can achieve a fair overview of the population treated in the asylum network.

Social Parameters of Asylum Populations Gender and Age Distribution Lipótmez˝ o, the largest of the three asylums in question, was originally designed for 500 patients, but furnished for 300 at the opening, and its equipment was only subsequently enlarged for 500 and 800. As Table 7.1 illustrates, there was a remarkable progress in the number of newly admitted patients (from the initial 300–400 up to as many as 950 a year by 1904) and their average daily number (which rose above 1,000 by 1900 and 1100 by 1904). The rising tide of patients exceeded the planned capacities and unavoidably resulted in a measure of overcrowding, a phenomenon typical for the period and similarly observed in other European countries.27

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Table 7.1 Annual admission and average daily number of patients at Lipótmez˝ o Public Mental Asylum (1868–1904) Year

Annual admissiona

Average daily number of patients treated

1868 1869 1870 … 1878 1879 1880 … 1888 18 89 1890 1891 … 1898 1899 1900 … 1904

93 411 298 … 320 351 290 … 532 477 556 568 … 763 718 701 … 950

– 264 439 … 569 598 578 … 752 732 756 734 … 923 1,010 1,030 … 1,128

Source István Hollós, “A lipótmezei állami elmegyógyintézet 40 évi betegforgalma 1868–1908” (Patient Admissions and Discharges at the Lipótmez˝ o State Mental Institution during the 40 Years between 1868 and 1908), Orvosi Hetilap (Medical Weekly) 53, no. 18 (May 1909a), 76 a The numbers of annual admittance do not comprise the patients remaining in the asylum from the previous year, thus do not represent the entire patient population in the given year

The dramatic increase of demand led thus to a significant overcrowding of local facilities, so that some of the inmates soon had to content themselves with sleeping on the ground due to a shortage of beds. Sheer numbers, as indicated in the table, point at the constant flow of patients in and out of the Lipótmez˝ o institute. In her highly influential study The Female Malady, Elaine Showalter argued that by the 1850s, madness had become a “female malady”: women came to dominate cultural representations of madness as well as the institutional reality of asylums and other mental institutions. Showalter saw it as a male-directed plot against women that aimed at enforcing norms prevalent in a patriarchal and in many ways misogynistic society. Although it is true that nineteenth-century views of female insanity appear to have been grounded in widespread social assumptions

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about women’s nature and social role, contemporary institutional data from Western states do not always support Showalter’s claim.29 What is more, in Hungary, major asylums show a qualified female minority among inmates. As Table 7.2 demonstrates, the over-representation of men can be equally observed in all three mental institutions. During its first 40 years of existence, altogether 20,526 patients were admitted to Lipótmez˝ o, among them a majority—59.6%—male. The sex ratio of the patient population at Nagyszeben asylum was largely the same during this period, though displaying in this respect an even less balanced situation. Out of the 6,506 patients treated in theTransylvanian city during its first 50 years, 4,159 or 64% were male. As to the private sector, during the first 14 years of the Schwartzer asylum, 198 or 55.5% of those admitted were men out of 357 patients. Thus, in each of the earliest major institutions for mental care, there was apparently a qualified majority of male clientele. In his study of the patient population, Hollós lengthily dwells upon the gender issue. He suggests an interesting factor of selective gender recruitment by comparing admissions from the capital and the countryside. According to him, more men were admitted from the countryside than from the capital, while women came more frequently than men from the capital. This appears to be particularly remarkable if one considers that before 1900 only one-third of all admitted patients were from Budapest. (The ratio changed after 1900 to 50–50%).30 To explain such disparities, Table 7.2 Gender distribution of patients treated in the asylums in the observed period Schwartzer 1850–1864 number Male Female Total

198 159 357

Nagyszeben 1863–1913

Lipótmez˝o 1868–1908

%

number

%

number

%

55.5 44.5 100.0

4,159 2,346 6,506

64.0 36.0 100.0

12,247 8,279 20,526

59.6 40.4 100.0

Sources Ferenc Schwartzer, A Budai Magán Elme- és Ideggyógyintézet tudósítója és tizenkét évi m˝ uködésének eredménye (Report on the Buda Private Mental and Nerve Institute and its 12-year Operation) (Buda: Ny. Bagó M, 1864), 10–14;Kálmán Pándy, Emlékkönyv a nagyszebeni m.k. állami elmegyógyintézet ötven éves fennállásának évfordulójára (‘Memorial Book’ for the 50th Anniversary of the Nagyszeben Hungarian Royal State Mental Institution) (Nagyszeben: Haiser György Nyomda, 1914); Hollós (1909), 78

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Hollós argues that the long travel from the countryside to the capital was more problematic for women than for men. He also considered that male patients for various reasons were generally “more cared for.” Being the family providers, their treatment was of more immediate need; they got more easily involved in conflicts in society, and their family nursing was less successful.31 Whatever the real explicative value of these arguments, they could, however, be only applicable to admissions from the countryside, and fail to account for differences in the gender ratio between the capital and the countryside. The higher number of male admissions (in general) could indeed be explained by the crucial role of (and therefore perhaps “more care for”) men as wage-earners. The higher rate of female admissions in Budapest might have been partly due to gradual changes in the traditional roles and career prospects of women. Following the rapid progress of urbanisation and related socio-economic transformations in city life, including the expansion of the participation of women in the work force, such developments accelerated in Hungary after the 1867 political compromise (identified as the Gründerzeit in local economic history), covering precisely the very decades under discussion. Tables 7.3 and 7.4 showing patients’ age distribution must be analysed together, since they complement one another. From Table 7.3 it is clear that admissions were indeed exceptional during childhood and adolescence. Mental illness, as treated in public institutions in the late nineteenth century, belonged to those of a mature age, but not the elderly. If the young were drastically under-represented (indeed practically absent below 15 years of age), the age cluster above 50 appears to be also less often (though not dramatically less) present. Hence the logical over-representation of the age groups between 20 and 50. Unlike the age pyramid of the general population, mental patients show an elongated structure at both ends and an enlarged centre. This structure appears closer to reality in Table 7.4 which omits the rare patients entering under 15 years of age. Here again, the most significant degree of over-representation appears in the 30–40 years old cluster. This can be partly explained by the very nature of the disorderparalysis progressiva (as the table shows, paralytics belong regularly to more advanced age groups than the average patients). This was a particularly serious disease at the time, the second most frequently diagnosed pathology in Lipótmez˝ o affecting some 24% of all patients (33.5% of men and 10.0% of women) and the most frequent in Nagyszeben, affecting

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Table 7.3 Age distribution of patients at admission compared to the population of Hungary by gender Age (years)

0–20 21–30 31–40 41–50 50All Number

Schwartzer 1850–1864a

Men

Women

Men and women (%)

Hungary 1900b (%)

Lipótmez˝o 1868– 1908c (%)

Lipótmez˝o 1901– 1902d (%)

Hungary 1900b (%)

Lipótmez˝o 1868– 1908c (%)

Lipótmez˝o 1869– 1915d (%)

12.0 27.2 28.3 21.6 10.9 100.0 357

45.6 14.8 12.8 11.2 15.6 100.0 8.372,000

8.6 26.0 31.4 22.0 12.0 100.0 12,247

7.1 27.5 24.7 26.7 14.1 100.0 397

45.5 15.1 12.9 10.8 15.8 100.0 8.465,258

13.1 31.3 28.1 16.4 11.2 100.0 8,279

10.1 32.0 29.9 16.5 11.5 100.0 2,921

Sources a Schwartzer (1864), 12 b Calculated from Magyar Királyi Központi Statisztikai Hivatal, A Magyar Korona országainak 1900. évi népszámlálása. 3. r. A népesség részletes leírása (Census of the countrie of the Hungarian Crown in the year 1900. Part 3: A detailed description of the population), Magyar Statisztikai Közlemények (Hungarian Statistical Communications) 5 (Budapest: MKKSH, 1907), 470–524 c Calculated from data in Hollós (1909), 75–83 d Own survey results, as above

Table 7.4 Age distribution of mental patients and paralytics at admission compared to the population of Hungary by gender above 15 years of age Age (years)

15–20 21–30 31–40 41–50 50All Numbers

Men

Women

Hungary 1900a (%)

Lipótmez˝o 1868–1908b (%)

Paralytics Lipótmez˝o 1868–1808c (%)

Hungary 1900a (%)

Lipótmez˝o 1868–1908b (%)

Paralytics Lipótmez˝o 1869–1908b (%)

15.3 23.0 20.0 17.5 24.2 100.0 5.381,000

6.8 26.5 32.0 22.5 12.2 100.0 12,008

0.05 5.0 40.2 37.5 17.2 100.0 4,099

15.7 23.3 19.9 16.6 24.4 100.0 5.474,000

11.4 31.8 28.7 16.7 11.3 100.0 8,122

0.2 11.2 37.6 32.5 18.4 100.0 821

Sources a Proportion of men and women in Hungarian population in 1900. Computed from Magyar Királyi Központi Statisztikai Hivatal (1907), 470–524 b Calculated from data in Hollós (1909), 75–83 c From data in Hollós (1909), 75–83

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21.0% of the patient population (27.7% of men and 8.9% of women) (see Table 7.14). It indeed hit most of its victims around their 40s. Men between 35–45 were specially exposed to this affliction due mostly to the progressively developing consequences of syphilitic infections following a long, sometimes 10-year period of incubation. Its relation to gender is evident: as Table 7.14 demonstrates, 83.2% of the paralytic patients were male in Lipótmez˝ o and 84.6% in Nagyszeben. Taking the entire male asylum population of the period, every third patient suffered from paralysis in Lipótmez˝ o, and their proportion was only slightly less in Nagyszeben (27.7%). The vast gender difference identifiable here with the overwhelmingly male recruitment of paralytics clearly attests to the gender-specific social conditions of the illness. Sexual promiscuity, supported by prostitution, provided a feeding ground for the infection of a large number of male clients and a few female victims, hence the marked over-representation of mature men among paralytics. On the whole, most women entered the asylum in the 21–40 age cluster (see Table 7.4). If the patient numbers—at least partly—follow the actual proportions of those falling ill in society, then women were most prone to mental and nervous disorders between 21–40 (60.5% of the female patients belonging to this age category). In other words, it is the age-group of 21–40 years where we see a considerably (8–9%) higher incidence of mental illness than as compared to the entire Hungarian female population. This tendency is generally explained in contemporary psychiatric texts by the enormous impact of female reproductive functions and biological processes proper on mental state (menstruation, pregnancy, childbed, breast-feeding, etc.).32 However, this theory of nineteenthcentury psychiatrists that gave so much weight to female biology is not corroborated by the figures. If the biological theory had worked, then numbers should show a marked increase in the number of female admissions in the age-group between 15–20 (equalling to the first years of puberty), while in fact they were underrepresented precisely here. The theory also does not hold in comparison with numbers concerning men. For them the age-category when the liability of falling mentally ill and being hospitalised in an asylum was slightly shifting upwards, although it was still highest in the age-group between 21 and 50 years. There the incidence of mental illness was higher than the age-group’s proportion in the entire male population: between 21–30 years by 3.5%; between 31–40 by 12%; and between 41–50 years by 5.5% (see Table 7.4). Therefore, while women’s predisposition to mental illness was evenly

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higher throughout the years 21–40 (by 8–9%), men’s predisposition, which was also higher, showed more unevenness in the years 21–40 and was still observable in the age-group between 41–50 years. The fact that the sex ratio shows a remarkable imbalance to the detriment of men in the years 31–50 can be clearly explained byparalysis progressiva. To give more evidence that the so-called menstrual or reproductive organs effect imputed by nineteenth-century psychiatrists to women seems to have been a myth rather than a biological cause that could be registered in institutional statistics, I constructed Table 7.5 of patients’ age-distribution from which I excluded the paralytic patients. (As stated above, the huge gender difference in the syphilitic disease paralysis progressiva was due to gender-specific social conditions and not to biology.) Table 7.5 which excludes paralytic patients demonstrates a much more balanced pattern of gender-specific age distribution: there was no spectacular over-representation of women in any age cluster compared to their male counterpart. This suggests that female reproductive biology did not affect mental disorders in a way that manifested in admission statistics. Not biology, but gender worked, via the social differences between Table 7.5 Age distribution of mental patients excluding paralytics at admission compared to the population of Hungary by gender above 15 years of age Men Age

Hungary 1900a (%)

15–20 21–30 31–40 41–50 50All Numbers

15.3 23.0 20.0 17.5 24.2 100.0 5.381,000

Women Lipótmez˝o, without paralytic patients 1868–1908b (%)

Hungary 1900a (%)

Lipótmez˝o, without paralytic patients, 1868–1908b (%)

10.30 37.64 27.85 14.73 9.60 100.0 7,909

15.7 23.3 19.9 16.6 24.4 100.0 5.474,000

12.65 34.12 27.69 14.92 10.50 100.0 7,301

Sources a Calculated from Magyar Királyi Központi Statisztikai Hivatal (1907), 470–524 b Calculated from data in Hollós (1909), 75–83

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women and men’s sexual practices: gender mattered not so much for women but rather for men, especially due to syphilis. Showalter is right in emphasising the prevalence of images of female madness in nineteenth-century society and psychiatry. The female icon of the hysterical woman, for instance, was undoubtedly pervasive in psychiatric writings and the cultural imagination of the period, and women diagnosed as hysterics in fact supplied a significant portion of the clientele of out-patient nerve clinics and hospital psychiatric wards. This female figure, however, has to be complemented with the figure of the demented male paralytic patient which equally marked psychiatric and cultural representations as well as the recruitment of the clientele of late-nineteenth-century mental asylums. Marital Status and Religious Affiliation Hollós stresses in his study the high number of married patients compared to unmarried, which seems to be even more striking if the number of those whose congenital illness (originally excluded the possibility of marriage) is removed.33 However, if one only considers the marriageable population of Hungary (without those under 15), and compare the number of married patients to the married population, and the unmarried patients to the unmarried population, one finds a significantly higher incidence of mental illness among the unmarried, as in Table 7.6. Over two-fifth of all patients were single in each of the major institutions studied, approaching the double of the proportion of the general unmarried population. Marriage, one could say, operated as a protective scheme against being sent to a mental hospital. Such “protection” can be explained in different ways. On the one hand, patients who fell ill at a relatively young age were mostly excluded from the matrimonial market. To this one can add that, in the youngest post-pubescent age group, most of those concerned (especially men) were not yet in a position to marry for social, economic and family reasons. On the other hand, matrimonial bonds may have operated a dual protection against being sent into a mental hospital. First, it is reasonable to presume that marriage offered family integration preserving many potential patients from some well-qualifiable risks of mental illness, for example—in concrete nineteenth-century terms—many young males from the exposure to the company of prostitutes, a source of syphilitic infection and paralysis already discussed. Classical studies of suicide (by

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Table 7.6 Marital status of patients in mental asylums as compared to the general population (in per cent) Schwartzera Nagyszebenb Male

Single Married Widow Divorced All Numbers

46.8 43.1 10.1 100.0 357

Lipótmezöc

Female Male

Female Total

Female patients 1869– 1915d

42.6 32.0 46.5 40.4 44.0 42.3 50.5 52.2 48.8 46.2 47.8 44.4 5.7 14.0 4.1 12.0 7.3 1.3 2.1 0.5 1.3 0.84 13.3 100.0 100.0 100.0 100.0 100.0 100.0 4,159 2,347 12,247 8,309 20,526 2,933

Hungarian marriageable population 1900e 23.5 62.1 14.4 100.0 5.474,000

Sources a Schwartzer (1864), 12 b Calculated from tables in Pándy (1914) c First three columns calculated from Hollós (1909), 75–83 d Survey results, see above e Hungarian population outside Croatia. Calculated following data in Magyar Királyi Központi Statisztikai Hivatal (1907), 527–540. Population above 15 years of age only

Durkheim, Halbwachs, etc.) suggest that marriage represents a similar protection against the temptations of self-elimination as well. Furthermore, the fact of being married must have contributed to the probability that the symptoms of a mental disorder would be dissimulated from the outside world, so that those concerned may less often be handed over to psychiatrists and interned. This may partly explain why such protection ceases to operate after the cessation of marriage, hence widows and divorcees are normally represented among inmates. While I argue for the general function of marriage as a protective scheme against both possible pathological risks and the liability of being sent into a mental hospital, it cannot be claimed that marriage itself could not in many cases contribute to mental illness and even provoke maliciousconfinements.34 Here an in-depth investigation is lacking to demonstrate the historically changing conditions of the medicalisation of mental illness in various social milieus. While unmarried and married female patients make up a lower percentage of their sex group compared to their male counterparts, widowed or divorced women have a higher representation than men in similar situation. Reasons for this can be both that female widows were more numerous in the general population (given the lower death-rate of

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women in all age groups), and perhaps also that widowed or divorced women were less able to provide for themselves and were thus more often subjected to the will of their relatives in decisions concerning mental hospitalisation than their male counterparts. Religion Substantial disparities emerge in a comparison of the statistical representation of inmates by denominations. This is and used to be in the nineteenth century even more a highly sensitive issue, given the controversial social and political position of the churches and religious clusters in a yet poorly secularised society, where socio-political divisions and cultural dispositions most often followed denominational lines and which constituted, in this respect (as discussed above), an especially complex societal set-up among modern European nation states. As to the liability of joining the cohort of inmates of mental asylums, a number of recurrent denominational patterns can be easily discerned in Tables 7.7 and 7.8 To start with the extremes, Jews form indeed the most significantly over-represented religious cluster in every mental asylum observed. They appear three-four times more often among inmates than their statistical weight in the total population would suggest. On the opposite pole of the scale,Greek Catholics and Orthodox were systematically and heavily under-represented, especially in the Budapest institutions. In Lipótmez˝ o, their relative size hardly reached one-fourth of their proportion in the nation-wide population, while they still appear only one-half as often among the Nagyszeben inmates as among inhabitants inTransylvania (where they already formed a majority, see Table 7.8). Between these extremes one can note the regular but not drastic overrepresentation of Roman Catholics and the somewhat lower the average presence of Protestants, at least in Budapest. In Nagyszeben though, both Catholics and Protestants, representing the propertied and politically dominant elites, appear in a markedly strong position, significantly over-represented as compared to their statistical minority status in the region. The high proportion of Jewish patients at Lipótmez˝ o could be partly explained by the over-urbanisation of the inmate population. Lipótmez˝ o recruited initially one-third, later one-half of its patients from Budapest which somewhat shifted the denominational recruitment of the asylum. The proportion of Jews in the capital (and in other large cities) was high

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Table 7.7 Mental patients by religion in Dualist Hungary as compared to the total population of the country (in per cent) Schwartzer Lipótmez˝o 1850– 1868–1908b 1864a Men Roman Catholic Greek Catholic Greek Orthodox Calvinist Lutheran Jewish Other All

Budapest Angyalföld 1884– 1913c

Women

Lipótmez˝o 1901– 1902d

Lipótmez˝o 1869– 1915d

Men

Women

Hungarian Population 1900e

56.8

55.3

57.2 NA

57.7

58.6

48.7

6.7

3.4

2.0 NA

1.8

2.4

10.9

12.0

3.1

2.8 NA

3.0

2.0

13.1

13.4 8.6 15.4 0.3 100.0

8.8 6.1 22.1 100.0

14.4 7.5 4.9 0.1 100.0

10.7 13.7

100.0

13.5 9.5 NA 6.2 6.1 NA 18.4 22.4 18.5 0.02 NA 100.0 100.0 100.0

Sources a Schwartzer (1864), 10–14 b Hollós (1909), 75–83 c Mark Goldberger, “A zsidók és a pszichés megbetegedések.” (Jews and Mental Illnesses), in Hetven év. Bikur holim beteggyámolító egylet (Seventy Years. Bikur holim Patient Aiding Society), ed. Dr. Salamon Stern (Budapest: Országos Bikur Cholim Betegeket Gyámolitó Egyesület, 1941), 100 d Survey results, as above e Magyar Királyi Központi Statisztikai Hivatal, Dénombrement de la population des pays de la Sainte Couronne Hongroise en 1900. 10. part. Résumé des résultats, Magyar Statisztikai Közlemények (Hungarian Statistical Communications) 27 (Budapest: MKKSH, 1909), 100. NA—not available

above that in the countryside: in Budapest it actually exceeded 20%,35 while their general representation in the Hungarian population was less than 5%. The more or less spectacular presence of inmates originating from either the politically hegemonic Western Christian religious clusters or— even more markedly—from the upwardly mobile Jewish groups undergoing a rapid process of cultural assimilation suggests that the distribution of beds in mental asylums followed the logic of the socially unequal development of “medicalisation” of Hungarian society, rather than a logic of inequality in terms of morbidity proper. No one knows the group specific numbers and relative proportions of the mentally ill. The data yields evidence only about those interned in asylums. The two may not correspond, but there is no way to verify it. What we know concerns asylum

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Table 7.8 Denomination of patients in the Nagyszeben Asylum (1863–1913) compared to that of theTransylvanian population (in per cent) Nagyszeben 1863–1913a

Roman Catholic Greek Catholic Greek Orthodox Calvinist Lutheran Unitarian Jews All

Transylvanian population 1890b

Male

Female

Total

All paralytic patients

Of all psych. alcoh. pat

22.7

21.6

22.3

27.7

22.6

12.7

13.7

14.4

13.9

10.5

11.7

28.3

22.4

21.3

22.0

16.4

28.9

30.9

15.1 19.1 2.4 3.5 100.0

14.1 21.4 1.5 5.6 100.0

14.8 19.9 2.1 4.9 100.0

19.5 18.6 2.6 4.6 100.0

10.8 21.6 1.6 2.8 100.0

14.6 9.3 2.6 1.7 100.0

Sources a First 5 columns computed from Pándy (1914) b Országos Magyar Királyi Statisztikai Hivatal, Magyar statisztikai évkönyv (Hungarian Statistical Yearbook) (Budapest: OMKSH, 1896), 37.

inmates only. Their unequal distribution can be explained by socially unequal access to and reliance upon medical care. It appears obvious that Jews, for instance, a group noted for their rapid progress accomplished during the period under scrutiny in terms of “modernisation”, as demonstrated by their strikingly high proportions in the intellectual professions and in the entrepreneurial bourgeoisie, would—based on the strength of their cultural, social and economic “capital”—more willingly and consciously seek psychiatric treatment whenever needed than other groups. This tendency could only be strengthened by the large number of Jewish doctors (one-half of the medical staff of the country36 ), the high level of urbanisation of the Jewish population and its high degree of relative over-schooling in elite education achieved by around 1900. Groups marked by these characteristics were also liable, due to their urban living conditions and confidence in the efficiency of medical science, to transfer their sick to the hospital.

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This, however, does not exclude other factors that could have contributed—if verified—to an actually higher incidence of mental disorders among Jews. The speedy assimilation of Jews in often hostile social environments may have been instrumental in the development of a range of tensions, potential sources of socio-pathological risks. Given the scarcity of available topical evidence in this field, a closer scrutiny of the problem cannot be undertaken here. Social and Professional Status The interpretation of the inequalities of recruitment according to the degree of medicalisation can be further confirmed by the distribution of patients by social and professional background. Pisztora’s source was a manuscript booklet prepared in 1885 by Ottó Babarczi Schwartzer with the title: “Statistical data of the Budapest Private Mental and Nervous Institutes over thirty-two years.” Pisztora could consult it in 1975 thanks to its owner Nándor Horánszky. His comments are worth to be quoted to make sense of the data he published on the social extraction of inmates. It is striking in these statistics that, on the one hand, members of the landed aristocracy were not listed as such, and on the other hand, those belonging to the army represented such a high proportion. Dr. Horánszky…observed that the high nobility only very rarely turned up in the institution, rather exceptionally, and then they were put mostly among ‘landowners’. Well to do magnates were indeed treated abroad or in their family. The big number of ‘soldiers’ can be explained by the fact that the institution received on a contractual basis honvéd officers and those of the common Austro-Hungarian army sent by the Mininstry of Defense. Among them there were field officers—rarely generals—, besides a small proportion of non-commissioned officers. Alongside the military category the annual report of the Institutes in 1894 listed paying inpatients and—in limited numbers—those assigned by the Ministry of Interior following the Institutes’ agreement, as well as other mentally ill treated thanks to foundation benefices…The founding director of the Institutes Ferenc Schwartzer himself had founded a number of such benefices. There were four classes of fees for treatment according to the medical service offered, ranging from 90 to 180 forints monthly.37

The numbers in Tables 7.9 and 7.10 definitely confirm that the

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Table 7.9 Social status of patients admitted to the Schwartzer Asylum (1850–1864)

From a “more educated class” From the (lower) middle class From lower class Altogether In numbers

309

Men (%)

Women (%)

62.6 34.8 2.5 100.0 198

50.3 39.0 10.7 100.0 159

Source Schwartzer (1864), 12

Table 7.10 Social status of patients admitted to the Budapest Private Mental and Nervous Institutes during 1853–1885 (in per cent)

Servant Peasant Craftsman Shopkeeper Student Teacher Cleric Lawyer Medical doctor Architect Other professionala Official Army officer Rentier Landowner Together

0.9 3.2 7.9 14.7 4.5 2.7 3.7 4,5 3.1 1.8 0.3 16.8 18.9 9.8 7.2 100.0

Lower class Lower class Petty bourgeoisie Petty bourgeoisie Petty intellectual Petty intellectual Petty intellectual Professional Professional Professional Professional Civil servant Civil servant Propertied class Propertied class

4.1 22.6

10.9

9,7 35.7b 17.0 100.0

a writer, an artist and a “minister” b The category “official” may include civil servants but also some

private executives. Source Ferenc Pisztora, “Adatok az Osztrák-Magyar Monarchia hazai pszichiátriai intézményeiben ápolt betegpopuláció szociális összetételéhez” (Data Regarding the Social and Professional Composition of Patients Treated in Psychiatric Institutions of Hungary and the Austro-Hungarian Monarchy, Orvosi Hetilap (Medical Weekly) 22 (1977), 2659

majority of patients of this first private psychiatric enterprise belonged to sectors of the educated elite and only a small minority to the lower social strata. One can also note the difference in the class distribution based on gender. Among male patients, the representation of the upper

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strata appears to be clearly dominant, while female patients came somewhat more frequently from the lower classes as well (with only half of them belonging to the upper classes). Significant social disparities can be grasped in a more consistent mode via other, more specific data available concerning the socio-professional recruitment of the state institutions of mental health care, as Table 7.11 demonstrates. Table 7.11 Hungarian mental patients in the dualist period by professional status (in per cent)

in agriculture servant, worker, blue collar craftsman, industrialist trader, shopkeeper private executive, clerk, “employee” free professional, artist, intellectual public employee, cleric, teacher, civil servant student propertied, other

Lipótmez˝o 1868–1908 Both sexesa

Lipótmez˝o 1901–1902 Menb

Lipótmez˝o 1869–1915 Womenb

Hungary outside Croatia active population, 1910c

10.0 31.0

26.5 36.0

18.0 35.2

60.2 23.6

24.0

3.4

12.3

5.7

9.0

7.3 5.6

11.0 4.1

1.8 1.4

5.7

2.2

21.0d

11.1

10.2

2.3

5.0e 100.0

3.4 1.1 100.0

0.2 6.8 100.0

5.0f 100.0

Sources a Based on Hollós (1909), 79 b Survey results, see above c Calculated from Magyar Királyi Központi Statisztikai Hivatal, Recensement général de la population des pays de la Saint Couronne Hongroise en 1910. 6. partie. Résumé des résultats, Magyar Statisztikai Közlemények (Hungarian Statistical Communications) 64 (Budapest: MKKSH, 1924), 260. Students are not listed since they were not regarded as part of the professionally active population d For all “intellectual” (that is “non-manual”) professions e % estimated by default (as the complementary proportion to 100), since it is not specified in the source f Army included

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It has to be admitted that Table 7.11 of occupational data is constructed on a technically rather shaky foundation, for two reasons. First, information in the sources were of poor quality, only some strikingly frequent categorical occurrences having been noted by Hollós for Lipótmez˝ o. Second, the categories used in the survey on Lipótmez˝ o case files and in the information related to the nation-wide active population— the latter fairly precise and well defined—do not always correspond. With these reservations, however, one may recognise some significant patterns. The most interesting among them is the very marked underrepresentation of inmates of peasant background or otherwise related to agriculture (propertied farmers, estate owners, agronomists). When about two-thirds of the active population in the country was engaged in farming, the proportion of this group hardly exceeded one-fifth of mental patients. Now such poor representation of the peasantry and affiliated social brackets also explains indirectly the rarity of those denominational clusters in mental asylums—like the Romanian, Ruthenian orSerbianGreek Catholics or Orthodox—the mainstream population of which was tilling the soil in the Hungarian Kingdom. There is no need to speculate about the rarity of the incidence of mental diseases among peasants, for which there is no available evidence. It is sufficient to suppose that peasant families had a much more problematic chance to place their sick under medical care in the absence or the rarity of rural doctors. They were probably much more reticent than others to abandon their sick to psychiatrists or an asylum (generally regarded as a shameful act of negligence in village communities). Rural residence also offered better facilities to keep those affected by illness in family households. The opposite may be assumed to mark the attitude of middle class or other more urbanised groups (most of the working classes included), hence their observed over-representation among mental patients. The social inequalities of recruitment among psychiatric patients thus have probably much more to do with the degrees of “modernisation,” urbanisation and incidentally “medicalisation” of various social groups, than with the statistical incidence of mental illnesses among them. This argument may equally yield the key to Jewish over-representation among patients, much discussed in the latter nineteenth century by social reformers, doctors and psychiatrists in Hungary just like all over Central and Western Europe. Jews need not to be “more nervous” or “neurotically inclined” than others, as often alleged in the specialised literature of the era. It is enough to observe that they belonged more often than

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other denominational or ethnic groups to urban middle-class strata liable to accede to—or even seek—medical treatment for their mentally ill. Hollós provided a small table demonstrating the occupational distribution of professionally active women among Lipótmez˝ o patients (see Table 7.12). There are two important insights suggested by the table. The first is implicit in the raw data: women with an independent income represented almost one-fourth (23%) of the entire female population admitted to Lipótmez˝ o over forty years (1,934 women with independent income out of the 8,279 female population). This is a rather high proportion, given the low rate of professional activity among women of this period, outside agriculture. The obligation (or the chance) of making a living out of professional activities perhaps appears thus, in the circumstances of the time, as a factor implying a pathological risk. This risk must have been highest among housemaids. Although more research is necessary to seek a statistical demonstration of the extent to which the social condition of housemaids prepared the ground for a high incidence of mental illness, it is probably not far-fetched to identify a strong “pathological bias” attached to household service at the time, since housemaids supplied close to three quarter (72%, 1,394 maids) of all professionally active female mental patients. Apart from the possibly “pathological nature” of their uprooted, exposed and powerless social condition—which can be confirmed and verified by evidence of the high Table 7.12 Occupations of women patients in Lipótmez˝ o with independent income (in numbers)

1868– 1880 1881– 1890 1891– 1900 1901– 1908 1868– 1908

Office-workers

Teacher Singer, Seam-stress actress

Seller Waitress Maid Total

-

21

1

55

3

1

209

290

3

29

3

97

7

1

247

387

5

31

7

98

4

7

385

537

21

32

4

83

15

12

553

720

29

113

15

333

29

21

1,394 1,934

Source Hollós (1909), 80

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frequency of suicides among them in the early twentieth century, as well as their marked inclination to enter into other forms of social deviance (like prostitution)38 —one can also remember that housemaids made up a rather typically urban cluster in their majority, thus more liable to be abandoned to medical treatment in cases of serious mental disorders. This must have been especially so, since members of the group were not protected—as social outcasts and territorial déracinés —by a surrounding social network of kin and allies normally operational for others in similar situations.39 The debates still raging in the history of psychiatry between supporters of the purely biological basis of mental disorders and those who explain mental illness merely via social circumstances seem to unjustly oversimplify the whole problem and prove to be historically blind. In nineteenthcentury psychiatric textbooks, the biological versus social factors in the aetiology of insanity were neither exclusive of one another nor so clearly separated. Schwartzer’s complex theory of mental illness as well as subsequent works by Ern˝ o Moravcsik,Jakab Salgó, Károly Laufenauer, etc., all emphasise the impact of both.40 The exclusive emphasis put on either the biological/organic or the social/psychic factors also results in a view of mental illness as a monolithic entity rather than a large pool of disorders that show remarkable differences as to their aetiology, symptoms and development.

The “Medical Parameters” of Asylums Problematic Taxonomy Before turning to the medical parameters of psychiatric care and discussing the frequency of certain mental diseases manifest in asylum statistics, a few points have to be clarified. Although throughout the long pre-nineteenth-century history of madness, certain forms of mental disorder were differentiated, “madness” was still traditionally conceptualised as a rather monolithic entity (demonstrated in earlier designations like “melancholy” or “hypochondria” being synonymous with “madness” in certain periods)41 in comparison with the dissolving of madness into numerous varieties of more clearly defined mental disease forms brought about by nineteenth-century endeavours at classification. It is enough to compare Schwartzer’s traditional six forms of mental diseases used in his 1858 book with the 45 different designations that

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were used in the diagnosis of female inmates at the Lipótmez˝ o asylum between 1868 and 1919.42 Even if many of these designations overlap by clearly referring to the same illness and include acute and chronic variations of the same disease, the number is still remarkable. Shifts in nosology were rather chaotic and still are today, in spite of the two widely used standard international classifications of mental diseases: the International Classification of Diseases—ICD—published by the World Health Organisation in Geneva and the Diagnostic and Statistical Manual of Mental Disorders—DSM—authorised by the American Psychiatric Association.43 The Hungarian terminology used for differentiating types of mental disorders in the period is highly confusing, was subjected to many changes and is especially difficult to match with similar Western terminologies. There were numerous shifts in the taxonomy itself, complicated by a mixing of Hungarian terms with German and French designations, Greek and Latin-rooted names used in the West. Due to the nationalist, patriotic sentiment that coloured Hungarian medical thinking from the early 1830s, the enthusiastic use of traditional Hungarian designations of disease forms (that essentially originated from everyday “folk” language) was pervasive in psychiatric writing up to the 1880s, when more attempts can be observed (especially in the work of Ern˝ o Moravcsik) to merge these with or exchange for more professional sounding designations used in Western discourses. The old Hungarian terms “˝ orült” and “tébolyodott” which have been synonyms for “madness” in colloquial speech are abundant in early writings.44 Both terms carry with them the romantic notions of a person out of his or her mind, in torn cloths, with an anguished expression on his or her face. A third designation “dühösség” literally means “state of fury” or “rage,” which was also synonymous with “˝ orült” and “tébolyodott,” that is, mad. Revealingly, however, these three designations appear as distinct categories in Schwartzer’s 1858 classification45 and are used as separate forms of mental disorder at the Lipótmez˝ o asylum in the period between ˝ 1868 and 1873. “Orültség,” however, disappears from the Lipótmez˝ o diagnostic categories by 1879,46 and although it still emerges in Moravcsik’s 1888 psychiatric textbook (the first comprehensive Hungarianmental pathology textbook produced after Schwartzer’s in 1858), “˝ orültség” is equated there with “acute tébolyodottság,” “vesania acuta.”47 From the earliest writings dühösség is also identified as mania, whereas tébolyodottság is later equated withparanoia. Creating order and consistency in this confusing field of shifting taxonomies and meanings of

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disease forms may never be achieved by historical analysis. A systematic decomposing of mental illness, and the tracing back the history of transformations in case of each individual disease form and their international synchronisation would be greatly desired but might never be achieved satisfactorily. I nevertheless point out a few further striking changes in Hungarian designations and their appearance-disappearance that carry great significance (Table 7.13). In order to highlight a few striking differences in the shifting taxonomy over the period, I compare Schwartzer’s categorisation to the categories used in Lipótmez˝ o female case histories in the periods 1869–1873, 1879– 1882 and 1889–1892 (as reconstructed through the survey), and to the taxonomy provided in Moravcsik’s 1888 book A gyakorlati elmekórtan vázlata (Outline of Practical Mental Pathology).48 There are several new disease forms separated by Moravcsik that did not appear in Schwartzer’s book and only gradually emerged in asylum statistics. Epilepsy only appears in Schwartzer’s 1858 book as a predisposing factor, not a form of mental disorder; “epileptic mental disorder” appears on a few Lipótmez˝ o case histories in the given periods (in the years 1869–1873, only four out of the 367 female patients—1.1%—were labelled with it; in the years 1879–1883, six out of the 377—1.6%; Table 7.13 Distribution of patients suffering from various mental illnesses in the Schwartzer Asylum by gender (1851–1863) Name of diseasea

Male (%)

Female (%)

Altogether (in numbers)

Melancholy (komorkór) Mania (Dühösség) Monomanie or partieller Wahnsinn (Egyes téboly) Folie or Verwirrtheit (Tébolyodottság) Dementia, Idiotism, Cretinism (Butaság) Simulation Delirium tremens All Numbers

10.6 27.3 33.8

25.2 26.4 29.6

61 96 114

12.1 12.6 1.0 2.5 100.0 198

8.8 10.1 100.0 159

38 41 2 5 357

Source Schwartzer (1864), 10–14 a Since there are no designations that perfectly correspond to these categories, I tried to match them with contemporary French and German designations Schwartzer refers to in his 1858 book and 1864 asylum report. Thus the designations preceding the brackets are the closest estimated names

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Table 7.14 Patient admission broken down by disease forms at Lipótmez˝ o and Nagyszeben Asylums Lipótmez˝o 1868–1908a

Melancholy Mania Amentia Acquired dementia Paranoia Paralysis Epil./Hyster Psych. alcoh Secondary Idiot. imb Not mentally ill Unknown Total (in numbers)

Male (%)

Female (%)

Total (numbers)

3.8 11.5 3.6 4.1 22.7 33.5 5.6 6.8 2.1 5.3 0.9 100.0 12,237

7.3 13.7 7.5 9.8 36.4 10.0 6.8 0.6 4.7 3.0 0.3 100.0 8,285

1,082 2,539 1,058 1,312 5,797 4,926 1,240 888 648 903 129 20,522

Nagyszeben 1863–1913b Male (%)

Female (%)

Total (numbers)

5.0 12.0 9.7 3.1 17.9 27.7 6.2 8.2 4.0 4.4 1.7 0.2 100.0 4,159

11.5 21.8 18.4 3.8 16.1 8.9 6.9 0.8 6.1 4.2 0.9 0.6 100.0 2,347

475 1,012 834 219 1,125 1,361 419 359 308 281 91 21 6,506

Sources a Calculated from Hollós (1909), 75–83 b Calculated from Pándy (1914)

and in the years 1889–1893, 29 out of the 666—4.4%). By the time of Moravcsik, “psychosis epileptica” had become a widely used mental disorder designation. Moravcsik’s “psychosis hysterica” had no equivalent in Schwartzer’s classification and it was not differentiated as a disease form (although Schwartzer refers to the “Mother uterus” as a triggering cause in his 1858 book). The Lipótmez˝ o female files from the years 1869–1873 and 1879– 1883 do not contain this category at all, and only one patient is labelled with it in the years 1889–1893. Among the 2,927 female cases coded in the survey between 1869 and 1915, there were only 57 women diagnosed as suffering from hysterical mental disorder or psychosis hysterica (which makes up less than 2.0% of the coded female cases). In order to correct arguments concerning the widespread nature of hysteria in the nineteenth century, we have to make an important distinction. Hysteria did not grow into a significant disease form among female patients at mental asylums, whereas hysterical patients’ presence at theuniversity clinic and hospital

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observation wards for mental and nervous disorders became much more notable by the end of the century. But the most curious case is that ofparalysis progressiva: a form not separated by Schwartzer. He did not discuss it in his 1858 book nor did he use it as a separate disease form in the 1864 asylum statistics. Schwartzer’s book reveals that he knew well Esquirol’s work who included a discussion on paralysis as well. Most probably, Schwartzer had knowledge of this disease and had patients suffering from it. Observing his descriptions of monomanie (partieller Wahnsinn) and mania (Tobsucht/Tollheit), many of his paralytic patients could have easily been included under these disease categories based on characteristic symptoms.49 According to my research, the first Hungarian articles that contain a description ofparalysis progressiva published in Orvosi Hetilap are written by the eminent internist Frigyes Korányi in 185950 and by the alienist Gyula Niedermann, Schwartzer’s assistant doctor at the asylum, in 1865. Korányi’s article is however primarily on syphilis and from an internist’ perspective, while Niedermann’s focused on it from the mental alienist’s point of view. Niedermann was aware of both early works51 on paralysis as well as recent research: he reviewed recent publications by Erlenmeyer, Meyer, Griesinger, Leidesdorf and Westphal. Furthermore, he stated that, based on his own observations, 12.0% of all patients in the Schwartzer asylum suffered from paralysis (for every five male patients, there was one female patient, most of them in their 40s). Reflecting on the widely held view, Niedermann recounted the usual sources of paralysis: debauchery, heavy smoking, strong coffees and trauma of the head.52 Original research on paralysis, however, did not begin until the middle of the 1870s in Hungarian psychiatric circles.53 Why did then Schwartzer not include paralysis in his book or asylum statistics? It is possible that Schwartzer did not want to label anyone from his private wealthy clientele with this rather stigmatising disease and simply included them undermania. Or, perhaps relying too much on traditional nosology, he did not yet consider it a separate form of mental disorder. In this case, the shift occurred in the early 1860s— when paralysis already appeared in Nagyszeben and Lipótmez˝ o.Paralysis progressiva is clearly listed in the Nagyszeben asylum statistics from its opening in 1863: during the first decade, there were 100 male paralytics that made up almost one-fifth (19.2%) of the entire male patient population in the period. At Lipótmez˝ o, in the years 1869–1873, only 11 out of the 367 female patients—3.0%—were labelled as paralytic; in the years

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1879–1883, already 3.7%; and in the years 1889–1893, 7.1%.54 (These numbers reflect the female population where paralysis was always much less frequent, see below). Admission Categories of Mental Disorders Table 7.14 clearly shows that paralysis andparanoia were the most frequently diagnosed disease forms in both asylums. In Lipótmez˝ o, paranoia was on the top: 28.0% of patients of both sexes suffered from it. In Nagyszeben paralysis was leading with 21.0% of patients of both sexes. The distribution of paranoia was more or less balanced among gender groups, though it differed slightly in the two asylums with a limited majority of female patients among all paranoid patients in Lipótmez˝ o as against a small majority of male paranoid patients in Nagyszeben. At the same time, paralysis in both institutions was, as already noted, a primarily male disease: 83.0% of paralytic patients were male in Lipótmez˝ o and 84.5% in Nagyszeben. Taking the entire male asylum population of the period, every third patient suffered from paralysis in Lipótmez˝ o,55 and their proportion was only slightly less in Nagyszeben (27.7%). The more detailed Table 7.15 (based on numbers from Nagyszeben broken down for decades) demonstrates that the actual number of male paralytics increased sharply, though gradually throughout the period, while their proportion among male patients also grew considerably, only to level out at close to one-third of the total after 1884. It is difficult to give account of the possible factors in this increase: to what extent this development was due to the actual multiplication of cases of paralysis Table 7.15 Proportion of paralytics among male patients at Nagyszeben broken down for decades

Years

1863–1873 1874–1883 1884–1893 1894–1903 1904–1913 1863–1913

male paralytic patients

all male patients

(number)

(%)

(number)

100 162 255 264 370 1,151

19.2 22.4 30.7 31.5 29.6 27.7

520 722 830 837 1,250 4,159

Source Calculated from Pándy (1914)

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in the male population exposed to the risk, to the relaxation of possible efforts to dissimulate the cruel disease in various social groups affected or else to the mere improvement of diagnostic methods allowing a better identification of the illness.Paralysis progressiva deserves a more detailed discussion since it grew into one of the most problematic mental diseases by the turn of the century, see more on it in Chapter 8. Discharges The last aspect of asylum care I discuss concerns the apparent efficiency of treatments based on data related to the discharge of inmates. Table 7.16 shows that during the 40 years between 1868 and 1908, 21.2% of all patient left Lipótmez˝ o cured (20.0% of the men and 23.0% of the women). If one adds the number of patients who left the institute improved, the figure increases to 39.9% and the comparison by gender suggests a better rate of improvement and cure for women (45.5%) than for men (36.3%). The percentage of cured or improved patients in Nagyszeben seems to be substantially higher (51.0%). There again women had a better chance to leave the asylum in an improved condition (57.6%) than their male counterparts (47.3%). Table 7.16 Discharges in the various mental asylums Schwartzera Lipótmez˝ob 1868–1908

Cured Improved Not improved Died Not ment. ill All discharges

Nagyszeben (3) 1863–1913

(%)

Male

Female Total

(%)

Male

Female Total (%)

(52.3) (14.2) (14.9)

2,330 1,907 2,689

1,802 1,742 1,906

4,132 3,649 4,595

(21.2) (18.7) (23.6)

810 995 383

508 690 214

1,318 (22.4) 1,685 (28.6) 597 (10.1)

(17.9) (0.7)

4,628 107

2,332 31

6,960 138

(35.7) (0.7)

1,560 644 70 21

2,204 (37.4) 91 (1.5)

(100.0)

11,661 7,813

Sources a Schwartzer (1864), 10–14 b Hollós (1909), 81 c Pándy (1914)

19,474 (100.0) 3,818 2,077

5,895 (100.0)

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Such data, however, as most others related to the definition of illnesses or the state of health of those entering the orbit of contemporary medical observation, must be critically interpreted—however “objective” they appear to be. They are indeed liable to be seriously biased following the judgement of doctors—heavily dependent on the personal impressions and uncertain diagnostic principles of the time. Doctors especially in private institutions catering for a high- or middle-class clientele could have been directly interested in discharge reports. The strikingly better proportions of cure and improvement at the Schwartzer institute (52.3% cure; 66.5% cure or improvement) may obviously raise such doubts. In addition, the notion of “improvement” is sufficiently vague to leave space to arbitrary interpretations. Considerations (partly or entirely) external to medical science, for instance with reference to a criminal record or family situation of a patient, could also enter into play when the decision for discharge was made. Leaving the asylum as officially cured or improved, however, could at any rate mean only temporary amelioration in many cases. Using Hollós’s numbers, about 23.0%, that is, almost every fourth patient who had left the Lipótmez˝ o asylum eventually returned.56 The high death-rate—an apparently less debatable issue—was a constant feature of the patient populations under scrutiny. According to our table, approximately the same highly substantial proportions of discharges—over one-third in Lipótmez˝ o and Nagyszeben—were due to death. The fact that Schwartzer’s death figures were much lower may be due to a number of reasons but not much to do with the therapeutic efficiency of the institution: social and sanitary selection of patients (of higher standing and better general health conditions), length of treatment, discharge policy (which could aim at the preferential dismissal of fatally affected patients, etc.). Fairly precise and detailed evidence is available for Lipótmez˝ o in the years 1899–1908 in reports published annually by the Ministry of Interior. For the last period chosen by Hollós, the death-rates among those discharged oscillated between 24.0 and 36.0%, mostly closer to the latter percentage.57 Given the much worse subsistence conditions in the asylum during the first decades, the death-rates must have been even higher initially. The category “not improved” includes both “irrecoverable” patients and those transferred to another institution for further treatment. In order to ease overcrowding at Lipótmez˝ o, other asylums and mental wards of hospitals in the countryside were used to take over a number

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of “irrecoverable” patients. In 1899, for instance, 9 men and 25 women were transferred from Lipótmez˝ o to Eger, 58 men to Gyöngyös, 6 men to Nyitra, 48 men and 77 women to Gyula.58 To conclude the findings of this chapter, the analysis of the rich and complex social statistics of mental asylums allows the critical revision of a number of claims prevalent in psychiatric historiography. While the nineteenth century gave rise to powerful cultural images of female madness and many psychiatric theories on female insanity reflecting socially prevailing ideas about woman’s nature and social role, madness did not become a female malady. The majority population of the mental asylums was male, and the figure of the demented male paralytic patient strongly marked the life of mental care institutions.Paralysis progressiva not only formed a major professional problem for psychiatry, but also posed grave moral and social questions concerning bourgeois values, prostitution and the sanctity of the family. It became a lived experience for numerous families that lost a family provider or a brother to the disease and had to face all its social consequences. The cultural and psychiatric prevalence of female insanity should not be overemphasised at the cost of obscuring the gender reality of contemporary asylum populations and the scale and social implications of paralysis progressiva. The analysis also demonstrates that certain nineteenth-century theories related to madness cannot be backed by institutional evidence. For instance, the enormous influence attributed to female reproductive functions and biological processes on the mental state—so frequently stressed in nineteenth-century psychiatric texts—is not at all supported by asylum statistics. Data curves did not show a marked increase in admissions of girls and young women in their first years of puberty, in fact they were underrepresented compared to their proportion in Hungarian female population. Similarly, the proportion of female patients in the youngest age-groups did not considerably exceed that of the male. Female reproductive biology therefore did not affect mental disposition in a way that became manifest in asylum statistics. What is remarkably visible is not how biology, but how gender worked in shaping asylum populations: how the social differences between women and men’s sexual practices (and the consequence of syphilis) affected asylum recruitment. The rich source of asylum files may yield little evidence of biological causes of mental disorders. The ethnic, denominational and professional data of asylum files seem to suggest the comprehensive logic of the socially unequal development of „medicalisation” of Hungarian society

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in the given period, rather than a logic of inequality in terms of divergent propensities for mental illness. This fact of course lies in the nature of the source material. While our data provides evidence only about those hospitalised in mental asylums, no one knows the numbers and relative group specific proportions of the mentally ill in the given nineteenth century society. In these institutions, however, the spectacular presence or absence of certain social groups can be explained mostly by the degree of that group’s „medicalisation”: that is, the socially unequal access to and willingness to trust and rely upon medical care. The over-representation of the politically hegemonic Western Christian religious clusters or the upwardly mobile Jewish groups undergoing a rapid process of cultural assimilation can be explained by their urban middle-class background and liability to accept or even seek medical treatment for their mentally ill. This interpretation, however, does not exclude the possibility that there could be either biological or socio-pathological risks that contributed to a higher incidence of mental disorder among certain social groups. Therefore, in addition to emphasising the richness of potential insights provided by original asylum sources, this analysis also warns us of their interpretative limitations.

Notes 1. Ethnicity is curiously missing here, see discussed below. 2. For influential Hungarian psychiatric textbooks that demonstrate this complex approach see, for instance, Jakab Salgó, Az elmekórtan tankönyve (Textbook of Mental Pathology) (Budapest: Franklin Társulat, 1890), Ern˝ o Moravcsik, A gyakorlati elmekórtan vázlata (Outline of Practical Psychopathology) (Budapest: Franklin Társulat, 1888), and Ern˝ o Moravcsik, Gyakorlati elmekórtan (Practical Psychopathology) (Budapest: Magyar Orvosi Könyvkiadó, 1897). 3. These were: large countryside colonies; small institutions specialised in the treatment of epileptics, “imbeciles,” “idiot children,” alcoholics, criminals, nerve clinics, etc.; family care. See discussed in detail in Chapter 6. 4. Such as modern neuro-anatomical and histological research, clinical and laboratory experimentation, etc.. See Chapter 5.

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5. According to an 1895 nation-wide survey, there were 25,071 mentally ill people out of the approximately 16 million Hungarians (21,736 in the countryside, 1,852 in towns, and 1,483 in state asylums), although the Interior Ministry admitted that this number could be double in reality. See Ministry of Interior, Magyarország elmebetegügye az 1900. évben (Mental Health Care in Hungary in 1900) (Budapest: Schmidl Sándor Könyvnyomdája, 1901), 4– 7. New surveys in 1900–1901 already estimated 34,000 to 44,000 mentally ill in the country. See Kálmán Pándy, Gondoskodás az elmebetegekr˝ol más államokban és nálunk (The Care for Mental Patients Abroad and in Our Country) (Gyula: Corvina, 1905), 388, 391– 392; Tivadar Forbáth, Adatok a magyar szegényügy rendezéséhez (Data Concerning the Organisation of Poor Relief) (Budapest: Márkus Samu Könyvnyomdája, 1908), 90. 6. These were: 120 beds at the Schwartzer private lunatic asylum, 200 at the Nagyszeben public lunatic asylum, 20 at the Eger and 170 at the Buda Hospitals of the Hospitaller Order, and beds at other public hospital mental wards. 7. Precisely 5,927: 2,638 in large asylums and 3,289 at different annex hospital mental wards. See Pándy (1905), 388, 391–392; István Hollós, “A lipótmezei állami elmegyógyintézet 40 évi betegforgalma 1868–1908” (Patient Admissions and Discharges at the Lipótmez˝ o State Mental Institution during the 40 Years between 1868–1908), Orvosi Hetilap (Medical Weekly) 53, no. 18 (1909a): 75–83, 77, Forbáth (1908), 89–90. 8. In England in 1800, in a population approaching ten millions, about 5,000 mental patients were held in specialised lunatic asylums (and about as many insane in workhouses, bridewells and jails). See Roy Porter, Madness. A Brief History (Oxford: Oxford University Press, 2002), 95;Edward Shorter, A History of Psychiatry. From the Era of the Asylum to the Age of Prozac (New York, Toronto: John Wiley and Sons, Inc, 1997), 5. A century later in Hungary with a 16,830,000 population, about 6,000 beds were available for mental patients. 9. See Forbáth (1908), 90, and Porter (2002), 112. 10. See ibid. 11. Shorter (1997), 47. 12. I calculated these numbers from Shorter who gives the relevant number of inpatients for every 1,000 population: in England in

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1859, 1.6 patients were hospitalised for every 1,000 population, in 1909: 3.7 patients for 1,000 people. Shorter (1997), 47. 13. I arrived at this number based on the facts that: 6,000 mental patients were treated in psychiatric institutions in a population of 16,830,000 in 1900. 14. Ministry of Interior (1901), 4. 15. Ignác Romsics, Magyarország története a XX. században (The History of Hungary in the 20thCentury) (Budapest: Osiris, 1999), 47. 16. Among these factors, Romsics emphasises the higher ratio of natural reproduction among the Magyars, the assimilation of non-Magyars, and the higher proportion of emigration among non-Magyars. See Romsics (1999), 47. 17. See table in Romsics (1999), 47. 18. See table in ibid. 19. See ibid. 20. Magyar Királyi Központi Statisztikai Hivatal, Dénombrement de la population des pays de la Sainte Couronne Hongroise en 1900. 10. part. Résumé des résultats, Magyar Statisztikai Közlemények (Hungarian Statistical Communications) 27 (Budapest: MKKSH, 1909), 100. 21. I explain some of these below. 22. For more on this, see Emese Lafferton, “The Magyar moustache: the faces of Hungarian state formation, 1867–1918,” Studies in History and Philosophy of Biological and Biomedical Sciences 38 (2007): 706–732. 23. Ferenc Schwartzer, A Budai Magán Elme- és Ideggyógyintézet tudósítója és tizenkét évi m˝ uködésének eredménye (Report on the Buda Private Mental and Nerve Institute and its 12-year Operation) (Buda: Ny. Bagó M, 1864). 24. Kálmán Pándy, Emlékkönyv a nagyszebeni m.k. állami elmegyógyintézet ötven éves fennállásának évfordulójára (Memorial Book for the 50th Anniversary of the Nagyszeben Hungarian Royal State Mental Institution) (Nagyszeben: Haiser György Nyomda, 1914). 25. These raw results have been gained from a co-operative research enterprise headed by Viktor Karády, funded in part by the CEU research support scheme and based on the quantified exploitation of coded serial informations contained in patients’ case histories. Coding was implemented on the case histories of all female patients

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(altogether 2,927) for the years 1869–1873, 1879–1882, 1889– 1892, 1899–1902, 1913–1915. The sample for men was limited to the two first years of the twentieth century only (according to the librarians at Lipótmez˝ o archives, the entire nineteenth male case history collection has been destroyed). I owe many thanks to Viktor Karády for his generous help with the material and discussion of interpretations presented in this chapter. 26. Hollós was physician at Lipótmez˝ o for almost three decades until the 1920s when he was retired because of his Jewish origin. Hollós was involved in the Hungarian movement of psychoanalysis, and translated Freud from German. After his retirement he published his memories of the years at Lipótmez˝ o written in literary style, entitled My Farewell from the Yellow House. 27. See Shorter (1997), 33–69 and Porter (2002), 89–123. 28. Elaine Showalter, The Female Malady: Women Madness, and English Culture, 1830–1980 (London: Virago, 1985). 29. Several Western critics have attacked Showalter’s basic claims, arguing that she ignored or misread statistical and cultural evidence when described insanity as a female malady and very onesidedly presented psychiatry as monolithic and hostile toward women—and mostly toward women only. See Nancy Tomes, “Historical perspectives on women and mental illness,” in Women, Health, and Medicine in America, ed. Rima D. Apple, 143–171 (New Brunswick: Rutgers University Press, 1992), Joan Busfield, “The Female Malady? Men, Women, and Madness in Nineteenth Century Britain,” Sociology 28 (1994): 259–277, and Peter McCandless, “A Female Malady? Women at the South Carolina Lunatic Asylum, 1828–1915,” Journal of the History of Medicine and Allied Sciences 54 (1999): 543–571. 30. Hollós (1909), 77. 31. See ibid., 77–78. 32. See, for instance, Salgó (1890), Moravcsik (1888) and (1897). 33. See Hollós (1909), 75–83. 34. An example for the latter is related by Jen˝ o Konrád at the First National Congress of Psychiatrists presented in Chapter 4. 35. Endre Kovács and László Katus, eds. Magyarország története 6 (The History of Hungary 6). Vol. 2. (Budapest: Akadémia Kiadó, 1987 [1979]), 1163.

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36. By 1910, for instance, 48.9% of all doctors in the Hungarian Kingdom were Jewish (which did not include those already converted to Catholicism), see Magyar Királyi Központi Statisztikai Hivatal, A Magyar Szent Korona országainak 1910. évi népszámlálása. 4. r. A népesség foglalkozása a f˝obb demográfiai adatokkal egybevetve s a népesség ház- és földbirtokviszonyai (Census of the countrie of the Hungarian Crown in the year 1910. Part 4: The population’s occupation correlated with main demographic data and the population’s housing and property ownership relations), Magyar Statisztikai Közlemények (Hungarian Statistical Communications) 56 (Budapest: MKKSH, 1915), 648. 37. Ferenc Pisztora, „Adatok az Osztrák-Magyar Monarchia hazai pszichiátriai intézményeiben ápolt betegpopuláció szociális összetételéhez” (Data Regarding the Social and Professional Composition of Patients Treated in Psychiatric Institutions of Hungary and the Austro-Hungarian Monarchy, Orvosi Hetilap (Medical Weekly) 22 (1977), 2659. 38. See Viktor Karády’s study of the social conditions of housemaids, Viktor Karády, “Felekezet, cselédsors és szexuális deviancia az 1945 el˝ otti Budapesten” (Denominations, Housemaids and Sexual Deviance in Budapest before 1945). In Zsidóság és társadalmi egyenl˝otlenségek (1867–1945) (Jewry and Social Inequalities, 1867– 1945), ed. Miklós Hadas, 141–166 (Budapest: Replika Kör, 2000b). 39. For the social conditions of housemaids, see Gábor Gyáni, Család, háztartás és a városi cselédség (Family, Household, and Urban Domestic Servants) (Budapest: Magvet˝ o Könyvkiadó, 1983), and Gábor Gyáni, Women as Domestic Servants: The Case of Budapest, 1890–1940. Studies in Hungarian Social History III, ed. István Deák (New York: Institute on East Central Europe, Columbia University, 1989). 40. See, for instance, Moravcsik (1888); Salgó (1890); Moravcsik (1897); Károly Laufenauer’s descriptions of nervous illnesses in Ern˝ o Jendrássik, ed., A belorvostan tankönyve (Textbook of Internal Medicine). Vol. 2. (Budapest: Universitas Könyvkiadó Társaság, 1914). 41. See Porter (2002). 42. Based on survey, see above.

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43. On problems of classification and the history of individual mental and nervous disorders, see for instance: Ian Hacking, Rewriting the Soul. Multiple Personality and the Science of Memory (Princeton: Princeton University Press, 1995); German E. Berrios, “Obsessional Disorders During the Nineteenth Century: Terminological and Classificatory Issues,” in The Anatomy of Madness. Essays in the History of Psychiatry. vol. 1., ed. William Bynum, Roy Porter, and Michael Shepherd (London: Tavistock, 1985), 166–187; Ian Dowbiggin, “Delusional Diagnosis? The History of Paranoia as a Disease Concept in the Modern Era,” History of Psychiatry 1 (2000), 37–69; German E. Berrios and Roy Porter, eds., A History of Clinical Psychiatry. The Origin and History of Psychiatric Disorders (London: Athlone, 1995). 44. “Maddoctor” is “˝ orült doktor” in Hungarian, and the lunatic asylum both “˝ orülde” or “tébolyda”. 45. See Ferencz Schwartzer, A lelki betegségek általános kór- és gyógytana, törvényszéki lélektannal (The General Pathology and Treatment of Disorders of the Soul, with Forensic Psychology) (Budapest: Lauffler és Stolp, 1858). 46. Such important changes in the categorisation are only revealed in the survey results which separately coded the disease names specified on each patient file in the chosen periods. Such shifts are concealed in Hollós’ numbers and the Nagyszeben charts since these reflect the unified and simplified classification used in public asylums at the end of the observed period imposed on earlier statistics as well. 47. See Moravcsik (1888). 48. Moravcsik (1888). 49. Schwartzer (1858), 128, 189. 50. Frigyes Korányi, “Egy tanulmány a bujasenyvtan köréb˝ ol” (Study from the Field of the French Disease), Orvosi Hetilap (Medical Weekly) 3, no. 50 (1959), 797–802. 51. Niedermann reviewed works by Haslam (1789), Broussais, Bayle (1822, 1826), Calmeil—(1826), Duchek (1851 Prague), Lunier (1849), Baillarger, Falret, Rokitansky, Mayer in the 1850s, Valentin. See Gyula Niedermann, “A terjed˝ o hüdéssel járó butaság” (Dementia Paralytica Progressiva), Orvosi Hetilap (Medical Weekly) 48 (1865), 975–981; 49 (1865), 999–1009. 52. Niedermann (1865), 975–981, 999–1001.

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53. See discussed in Chapter 5. 54. Based on survey. 55. Hollós claims that paralysis mostly hit patients of intellectual occupations. During this period between 1868 and 1908, out of 100 admitted judges, 78 suffered from paralysis, while out of 100 daylabourers only 22, and out of 100 peasants only 15. More than half of all admitted officials (1,435) suffered from paralysis. 56. Out of the 20,526 patients during the 40 years, 1,807 were readmitted several times. This can be considered very high compared to those who left the asylum recovered or improved. (The incurable patients, many of whom were transferred to other asylums and small psychiatric wards at hospitals in the countryside, as well as the dead, were obviously not likely to return to the institute). 57. My calculations based on numbers provided in the annual reports by the Ministry of Interior. See Ministry of Interior, Magyarország elmebetegügye az 1899–1908 években (Mental Health Care in Hungary in 1899–1908). 10 vols. (Budapest: Schmidl Sándor Könyvnyomdája, 1900–1909). 58. Ministry of Interior (1901), 9.

CHAPTER 8

Invading the Public and the Private: The Hygiene of Everyday Life, Shell-Shock and the Politics of Turn-of-the-Century Psychiatric Expertise

Shifts in the Social Functions of Psychiatry by the Turn of the Century Characterised by diverse social composition as well as political and ethnic conflicts, late-nineteenth-century Hungary provides the exemplary model of the coexistence of fierce nationalism and fervent cosmopolitanism. The interaction of these forces deeply shaped the country’s medical and human sciences. Manifestations of a perceived degeneration within “civilisation”: capitalism, socialism, feminism, anarchism, the Decadent movement, crime, high suicide rates, and insanity, became signifiers of cultural crisis that contemporary scientists translated into a language of social pathology. In the following, I focus on psychiatrists’ contribution to this process. After the lengthy process of building a professional institutional system in the country starting in the 1850s, by the turn of the century, Hungarian psychiatry gradually moved beyond its closely defined disciplinary borders and increasingly became a public arena. As this chapter demonstrates, psychiatrists extended their professional expertise, originally focused on the individual person and the patient population within psychiatric institutions, to the larger social domain, encompassing crowds, masses, cities © The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 E. Lafferton, Hungarian Psychiatry, Society and Politics in the Long Nineteenth Century, Mental Health in Historical Perspective, https://doi.org/10.1007/978-3-030-85706-6_8

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and the nation. Parallel to this development concerning the health of society, psychiatrists also gradually attained a cultural monopoly over the “hygiene of everyday life” and, by the first decades of the twentieth century, invaded the private spheres of ordinary families and individuals. These tendencies resulted in what Elizabeth Lunbeck called the spread of psychiatric perspective1 in society, unconnected to psychiatric institutions. The task of the psychiatrist now was to intervene in solving grave social problems, such as alcoholism, pauperism, prostitution, syphilis, sexual perversion and insanity; this crystallised in the hygiene of a healthy mental and physical “everyday” life in which prophylactics figured prominently. Such an extension of the psychiatric expertise into the public domain is well illustrated by the asylum director Gusztáv Oláh who argued that the: decent isolation and treatment of dangerous mental patients is only secondary, police duty. The national economic and cultural centres of gravity of state mental health care lie elsewhere. (...) In our age marked by nervous disorders, social and individual medicine have an enormous impact on our social and national development. Bringing mental asylums closer to life, ending their exclusive character, attacking mental problems in their roots, fighting alcoholism, and above all, keeping the ability of masses of chronic mental patients to work and contribute to social life, these are the worthy tasks of the public health care of the new century, which will be undoubtedly marked by an action of social rescue.2

Degeneration, Social Problems and Prophylactics The population of psychiatric institutions in the last decades of the nineteenth century suggests a strong correlation between grave contemporary social problems and psychiatric illness. The rise in the number of paralytics, alcoholics and neurasthenic patients (neurasthenia was perceived as an “epidemic”) made social factors become ever more relevant in psychiatric thinking. A proliferation of books and articles by well-established psychiatrists on a few topics contained strong social criticism targeting alcoholism, prostitution, pauperism, and the consequences of capitalism and civilisational forces. These social factors and elements of organicism combined in the all-pervasive theory of degeneration to which numerous Hungarian psychiatrists full-heartedly subscribed.3

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This growing literature produced by psychiatrists with very different backgrounds demonstrates a significant shift and expansion in psychiatrists’ understanding of the profession’s role and function by the turn of the century. Claims of professional expertise, originally focused more on the individual person and the patient population within the psychiatric institution, were now extended to the larger social domain. The health of society was now at stake, and it was explicitly argued that it was psychiatrist’s task to intervene in social problems and solve them with his expertise. Prophylactics became a key concept in turn-of-the-century psychiatry. “Human society reacts to pathological conditions not through the individuals, but as a single body,”4 therefore psychiatry’s greatest task was the development of “prophylactics that encompasses social life and extends to several generations” (22, 60). Prophylactics became increasingly important in numerous psychiatric works that placed more emphasis on aspects of healthy living and constructed the hygiene of a healthy mental and everyday life.5 From among the numerous examples, the mental pathologist and asylum doctor Károly Lechner’s6 argumentation nicely illustrates this “new mission” of the psychiatrist and introduces most of the topics that are discussed in detail below. At the Second National Alienist Congress in 1902, and in a Darwinian vein, Lechner discussed in detail three of the most dangerous factors in the “struggle for existence and race preservation”: alcoholism, syphilis related to prostitution and “pauperism,” all of which resulted in the mind’s exhaustion.7 In his argument, alcohol, prostitution, pauperism and crime interact in a vicious circle, tied together by the concept of degeneration. “The abuse of alcohol leads to the degeneration of the organic structure and the psychic character, and to early death. … But its greatest curse is that the degeneracy of the alcoholic’s cerebrum is passed down for four generations within the family” (119). Likewise, prostitution generates syphilis, syphilis generates degeneration that thrusts many into prostitution, into vice, others into alcoholism, again others into insanity due to paralysis progressiva or tabes dorsalis. (…) Paralysis, inflicting a quarter of all the mental patients, attacks its victims in the prime time of their manhood, … it begins with an early moral blindness, and destroys whole families before it kills the patient. (119)

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The solution was not simply what characterized earlier psychiatric belief: the patient’s cure through individualized treatment. What the new solution added to this was intervention on the social level, the elimination of the social roots of mental illnesses implemented with the psychiatrist’s expertise. “To stop the quick further spreading of paralysis progressiva throughout the country can only be achieved by the overall reform of prostitution. In this, the psychiatrist has to give a helping hand” (120). Similarly, in cases of pauperism and poverty, which, according to Lechner, directly affected the brain but also brought with it parasitism, work avoidance, vagabondism, alcoholism, and vice, all of which predisposed one to mental illnesses and formed “the hotbed not only of mental disorders, but dangerous social maladies of anarchism and nihilism,” the solution was again intervention on the social level with the active participation of psychiatrists in establishing further public charity institutions and designing better policy aimed at the poor. The psychiatrist no longer posed simply as the master of the deluded mind and nervous disorders, but also as the healer of social maladies. With his expertise, he claimed to intervene into the formation of policy towards the poor, and thus improving their living and working conditions, defining the principles of child-rearing, etc., “according to the guidance of the professional psychiatrist” (120–121). Neurasthenia or Nervous Exhaustion Our century has been marked by many kinds of adjectives. The extended use and irreplaceability of iron, the rails that run across the globe, the spread of machines, all would justify our choice to call our century the age of the iron. The wonderful achievements of electricity in the last decades, the telegraph, the telephone, the electric light and rails … could urge us see our century marked by electricity. But it does not deserve any designation so much as “nervous.”8 Not any of the previous centuries have been marked by so many qualifiers as ours, but among the many qualifiers, the one that captures best the nature of the period ... is the one that stresses nervousness as the characteristic of the era. What is more, by now we have to talk about not only nervousness, but rather nervous disorders...9

Similarly to Lechner, the mental pathologist and Lipótmez˝ o asylum doctor Jakab Salgó’s argumentation in his 1905 book A szellemi élet

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hygienája (The Hygiene of Mental Life) conceptualises problems on the social level and defines the psychiatrist’s job as no less than “to restore the shaken health of society’s organism.”10 Building on theories concerning the chemical processes that underpin mental activities in the central nervous system, as well as on the results of German experimental psychology, in his book, Salgó elaborates on a complex hygiene of mental life with its psychological ramifications. “Modern mental work as well as social life” are the predisposing factors that lead to the overexertion of the nervous powers and result in mental exhaustion. In Salgó’s argument, “the character of modern mental work, the contemporary form of the use of mental powers is not only dangerous to the exhausted individual but endangers society more than any devastating epidemic.”11 Salgó’s psychologically informed social criticism extended to the “gentlemanly” aspirations and exaggerated needs of the gentry, to the powerful role of the bill of exchange in people’s mental life (“how many men’s lives have been ruined by the bill!”), and to workers’ housing conditions, unsatisfactory nourishment and low salaries, all of which contributed to the exertion of mental and life powers. Although most of these factors are very similar to those enumerated in the first Hungarian mental pathological textbook written by the alienist Ferencz Schwartzer,12 by the turn of the century this criticism was espoused with a claim of the psychiatrist’s expert intervention in these very social problems. Not all mental disorders linked to the nerves had a confirmed anatomical cause. The increasingly “popular” psychic disease of neurasthenia— “the weakness of the nerves”—was said to be a nervous disorder that was manifested in psychic symptoms due to the “pathological excitability and functional weakness of nerve-centres in the cerebral cortex and the subcortical area,” although its anatomical basis was admittedly unknown.13 Yet neurasthenia or “nervousness,” like the vapours and the spleen of the eighteenth century, became omnipresent in society.14 Nervous disorders were perceived as epidemic, and “nervousness” became a rich and pervasive social metaphor for the whole age. The notion of nervousness got entangled with the concept of degeneration,15 but also with the disease paralysis progressive and war neurosis, as we will see below.

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Paralysis Progressiva and Female Emancipation As asylum doctors, we are used to the fact that every third patient … with shuffling steps, stuttering speech and destroyed psyche is the living evidence of the destructions of a horrible disease.16

Paralysis progressiva was a particularly serious and devastating form of mental affliction due mostly to the advanced stages of syphilitic infections following a long, sometimes ten-year period of incubation. Once it broke to the surface, it manifested itself in increasingly grave mental and bodily symptoms: tremors, foot dragging, muscle wasting, bragging, megalomania, and in the final stages, complete mental derangement. As I have shown in Chapter 7, paralysis progressiva was the second most frequently diagnosed pathology in Lipótmez˝ o affecting 24.0% of all patients (33.5% of men and 10.0% of women) and the most frequent pathology diagnosed in Nagyszeben, affecting 21.0% of the patient population (27.7% of men and 8.9% of women). (See Table 7.14 in Chapter 7.) It indeed hit most of its victims around their forties (men between thirtyfive and forty-five were especially exposed to this due to the ten-year latency period) and its relation to gender is evident: 83.2% of the paralytic patients were male in Lipótmez˝ o and 84.6% in Nagyszeben. Taking the entire male asylum population of the period, every third patient suffered from paralysis in Lipótmez˝ o, and their proportion was only slightly less in Nagyszeben (27.7%). (See Tables 7.4 and 7.14 in Chapter 7.) The vast gender difference identifiable here with the overwhelmingly male recruitment of paralytics clearly attests to the gender specific social conditions of the illness. Sexual promiscuity sustained by prostitution provided a feeding ground for the infection of a large number of male clients and a few female victims (hence the marked over-representation of mature men among paralytics). Paralysis progressiva thus not only formed a major professional problem for psychiatry, but also posed grave moral and social questions concerning bourgeois values, prostitution, and the sanctity of the family, and became a lived reality for numerous families that lost a family provider or a brother to the disease and had to face all its social consequences. Unlike alcoholism, which more often affected the lower classes, paralysis progressiva’s victims primarily came from the middle and upper classes. According to the Lipótmez˝ o mental asylum doctor, István Hollós,

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compared to the 30–35% of paralytics among the mental asylum population, out of one hundred judges brought to mental institutions, seventyeight were paralytic; out of one hundred lawyers, seventy were paralytic; out of one hundred engineers, officials, actors, pharmacists, etc., fifty to sixty were paralytic; and out of one hundred physicians, there were fortyfive. As opposed to these numbers, out of one hundred peasants brought to the mental institution, only fifteen suffered from paralysis.17 Oláh connected paralysis to intelligence and mourned the enormous “damage done to the state due to the amount of reason lost mostly as a result of syphilis.”18 Concerning the cause of paralysis, in 1913 the clinical psychiatrist László Benedek concluded: “paralysis can only arise in someone infected by syphilis, often in the presence of predisposing factors.”19 Although by around 1900 many Hungarian doctors suspected that the syphilitic infection was behind the disease, it was still contested. Director of the Angyalföld State Mental Institute, László Epstein, for instance, referred to a growing understanding of the role of syphilis as an important— though not exclusive—aetiological factor in several nervous and mental disorders, such as tabes and paralysis progressive, as well as certain forms of neurasthenia. Epstein thus designated the fight against syphilis as a first step in prophylaxis.20 Hollós also argued that the syphilitic origin was not yet proved, and hence, he only considered syphilis as one of the frequent conditions associated with paralysis progressiva, just like heredity and “psychic influence.”21 In his argument, it was the “psychic element” that was present in the case of all paralytics and which affected the nervous system of humans. The way the “physical organism has a hygiene, which contains the laws of material life processes as well as of normal and abnormal work,” so there must be a set of laws for psychic life, which determine what is “normal” psychic work and what mental activity counts as dangerous which “after a certain duration inevitably leads to disease” (18). Later a follower of psychoanalysis, Hollós emphasised the role of “psychic damages” that affect a person sometimes starting in childhood, which may culminate in disease. In a vague sense therefore, “mental exertion” or “emotional shocks” as psychic conditions of a person may make him or her diseased. Hollós came up with the basic fundamentals of a “hygiene of psychic work” encompassing “everything from elementary sensation to the creation of the genius”: the right balance between work and rest. This rhythm of work and rest, present in nature and in physical work, is often

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disrupted by our life embedded in modern culture, due to the excitement of alcohol and numerous refined pleasures (22–23). Salgó similarly saw paralysis progressiva as the most extreme form of mental exhaustion and stated that “paralysis is the disease of the intelligence, that is, it takes its victims from the ranks of mental workers.” Completely disregarding the syphilitic aetiology, he blamed it on the “tiresome, consuming nature” of mental work at the expense of rest. With tables on Lipótmez˝ o paralytic statistics, Salgó argued that age, occupation, sex and marital status all supported the notion that paralysis developed from mental exhaustion.22 While most doctors blamed the fact that men generally fell prey to paralysis between thirty-five and forty-five on men’s sexual habits and the ten-year incubation period of the disease, Salgó explained it with the sociological burden of founding a family. Salgó explicated the far greater frequency of paralytic men compared to women with men’s “5–6 times greater mental exertion” in society (140–141). Salgó, however, observed a recent increase in the number of paralytic women and explained it with social changes: the more intense mental life of the female sex and their struggle for independence, which he believed carried grave dangers. “The louder and louder demands of the female sex, the stronger emphasis on their individual values, … their war for social and economic independence, and their resulting greater mental exertion all have express signs” not so much in the success of the feminist movement, but in the “speedily increasing number of paralytics” (142). Epstein was also pessimistic concerning the impact of the feminist movement. Apropos of an international child protection conference that was to be held in Budapest on the turn of the century, Epstein proposed that “child protection must begin with the parents” and voiced his fears concerning a new phenomenon unfolding in the past decade or two: The social movement of our age wants to lead woman into the struggles of life, that is, it wants to expose her to the detrimental effects of all those factors which caused mass neurasthenia among men and resulted in considerably higher incidence of mental disorders among men than women, in spite of the fact that nature would require the opposite, given that a whole range of causes that trigger or predispose for mental disorders are hidden in women’s sexual as well as mental and emotional life, from which men are fully saved.23

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Woman was endowed with a weaker nervous system than man and would suffer earlier and more under “intellectual and physical exertion,” Epstein prognosticated. The “product of the so-called female emancipation” will be the “neurasthenic woman increasingly predisposed to mental illnesses.” Rather than “countervailing male neurasthenia with her healthy nervous system” for the benefit of the nascent embryo, she will “advance and precipitate progressive degeneration” (513). Alcohol Problems, Class and Crime Our age is the age of alcoholism. The alarming rise in alcohol consumption is the evidence of this. (…) Our era is the last stop in a vanishing world. It was in our time that the natural principles of individual and racial life became known. These principles undermine the prejudices of a millennium: that for work and the pleasures of life, we need drugs, most of all alcohol.24

The shift in psychiatrists’ assumed social role and function is also manifest in the fight against alcoholism. The task was no longer to provide expert help to the individual patient in his recovery from delirium tremens, but prophylactics and intervention on the social level. Psychiatrists’ active involvement in the temperance movement can be observed starting in the 1890s in the spectacular increase in publications on the topic in more popular and general journals, such as the Az Egészség (Health), the newly launched Alkoholizmus (Alcoholism), Népjólét (Public Welfare), Közegészségügy (Public Health Care), Klinikai Füzetek (Clinical Papers) as well as in traditional medical forums like Orvosi Hetilap (Medical Weekly) and Gyógyászat (Medicine).25 Budapest doctors, medical students and intellectuals collected signatures and turned to the English Good Templars Order to establish a Hungarian branch. In 1901, the Hungarian free masonic lodge named “Egészség” (Health) (and alternatively referred to as the Good Templars’ lodge) was founded by the psychiatrist and Royal Councilor Fülöp Stein and the Lipótmez˝ o psychiatrist István Hollós.26 Its chief task was the organisation of an anti-alcohol movement. The 10th International AntiAlcoholism Congress organised by Stein and held in Budapest in September 1905 was probably the largest such assembly of the period with more than one thousand registered participants.27

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The psychiatrist Gyula Donáth, a member of the masonic lodge, was probably the most active spokesperson of the movement among his colleagues. In his memoir, Donáth28 relates the activities of the Hungarian Good Templars according to which they convened highranking army officers and emphasised the importance of soldiers’ abstinence in these meetings long before the First World War (35). They organised anti-alcohol campaigns in factories combined with milkpropaganda, and published pamphlets entitled “Tej és alkohol” (Milk and Alcohol). In Donáth’s optimistic account, these had good results: “factory workers are drinking milk instead of beer” during their breaks at work (36–38). Members of the masonic lodge approached sport associations and published their findings related to a healthy lifestyle. To raise the “intellectual level” of the public, the Good Templars organised concerts and free lectures on scientific and artistic topics, all of which began with “appropriate and colourful anti-alcohol propaganda” to fight this “curse of humanity.” After the First World War, the government and Budapest city council withdrew their financial support from the Good Templars due to the post-war economic situation (36–38). In psychiatrists’ accounts, the alcohol problem was also approached from the perspective of national economy. Lechner criticised countries where the state saw the monopoly of alcohol as an important source of income, and opposed alcoholism with the much higher costs associated with institutional networks (hospitals, prisons and police) that aimed to reduce the social damage caused by alcohol. Donáth scourged the “alcohol capital” and thought that state prohibition would be needed.30 Lechner proposed the establishment of special asylums for alcoholics, and asked for the qualification of drunkenness as an “offense” and for the placement of alcoholics under custody. Writings on alcoholism were permeated with degenerationist thinking and strongly connected to the lower classes and crime. Epstein referred to his “experience paired with observation” to suggest that the children of alcoholics showed the “gravest signs of degeneration and very often suffered from epilepsy”. He believed that a large portion of the criminals, precisely the ones who committed the greatest crimes, were alcoholics (in addition to the epileptics). Furthermore, alcoholism “accelerated the onset of paralysis and can in itself produce symptoms similar to those of paralysis.” Oláh contended that, “among the lower classes, the daylabourers and coachmen, there are hundreds of thousands of alcoholics … who morally slowly roughen, become animalistic in their souls, and

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procreate those anti-social offspring who form the…youth of the society of the urban outskirts.”32 The forensic and clinical psychiatrist Ern˝ o Moravcsik established firm links between crime, degeneration, alcoholism and a number of other social problems: [W]e have to differentiate between the miscreant proper, in other words, the habitual criminals, and those who are plunged into sin by accident and unfavourable conditions. The miscreants proper are mostly born, raised, and develop in an inferior atmosphere in which poverty, privation, financial problems, debauchery, loose moral and legal understanding, the bluntness or lack of obligation and sense of decency, antisocial inclinations, and a predisposition to commit forbidden crimes all produce a special character from generation to generation. Due to life’s vicissitudes, these mostly degenerate, tainted individuals are more liable to the influence of alcohol, are more exposed to syphilitic infection and head injuries.33

Lechner claimed that alcohol was the source of 20 to 30% of all mental disorders and was the chief cause of 70 to 80% of all crimes committed.34 “The Goals and Purposes of the National Anti-Alcohol Association” referred to statistics from prisons, asylums and hospitals when stated that “alcohol is the cause of illnesses and crimes in 50– 60% of cases in these institutions.”35 Oláh also quoted statistics when he argued that “more than 50% of asocial and anti-social individuals descend from alcoholic parents.”36 The main solution to the alcohol problem as envisaged by psychiatric experts writing on the topic or active in the temperance movement was complete abstinence!37 To achieve this, psychiatric experts conjured many concrete ideas for social intervention, as Oláh’s enumeration prove: we need measures so that the people hear in their church, in schools, from their masters, and their priests not that alcoholism is a sin, but that wine is harmful, it does not give strength, but rather takes it away, that some of the alcoholic’s children will be epileptic, or idiot, or arsonist, or sickly. In the army, honour badges should be given to the abstinent. If the youth engaged in sports made drinking water fashionable, it would soon meet followers. ... In institutions and workshops premium should be promised to abstinent workers, all payment in kind in wine, with wine money or wine fee, should be abolished. All private companies should be approached to enforce similar measures towards their workers. Further tools would be

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the subsidy of abstinent associations and civic societies, and the support by the state of all fights that are directed against the abuse of alcohol.38

All these diagnoses of turn-of-the-century social problems related to mental health and proposals for curing society of these ills demonstrate the firm voice and boundless ambition of a new kind of expert, the psychiatrist in the service of society rather than the individual mind. Darwinism, Lamarckism and Elements of Eugenic Thinking It is undoubted that the tackling of the discussed social problems by medical/psychiatric professionals involved contemporary biological thinking and an organicist approach to the social body. Informed by Darwinism, degenerationist and eugenic thinking, at the Second National Alienist Congress in 1902 Lechner claimed that degeneration and certain pathological dispositions were “the tools” of natural selection and that nature’s aim to “muster out the weak and unfit” served the interest of the majority in the end.39 Epstein called attention to a pool of transitory disorders on the “wide borderlands between sanity and insanity.” He meant by this those “degenerates” [elfajultak] who are called by the French since Magnan “dégénérés superieurs” or simply “desequilibrés,” or by the German mental doctor Koch “Psychopatische Minderwerthigkeiten.” We see in them the workings of the iron hand of nature, which destroys everything – not suddenly ... but consistently and certainly – that proves to be flawed, that is not suitable for its function, and which literally punishes the sins of the fathers in their offsprings for three and four generations. The acquired nervousness of the parents, their neurasthenia, manifests itself in neuropathic habitus and moral depravity in their children; we find alcoholism, organic brain disorders, serious neurosis in the grandchildren; the fourth generation shows psychic disorders, as well as a predisposition for violent, criminal acts and suicide; finally we see in the fifth generation – besides the complete dullness of the intellect – the cessation of the capacity of reproduction and the damned family dies out. Luckily, a very few families slip down on this dangerous, Morellian slope due only to the most disadvantageous circumstances.40

In a deeply Darwinian and eugenic language, however, Epstein also mentioned forces that countered this “ingravescent degeneration,” so that

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the “germs of pathology seeded in the organism through inheritance” could weaken or die out and the diseased stock may recover. “Interbreeding with healthy blood” was the first method of the prophylaxis of mental illnesses, but Epstein also mentioned the “merciless scrapping [kiselejtezés ] of deficient human material [emberanyag ] as well as its opposite selection of the healthy, strong elements for the purpose of the preservation of the species” as correcting tools.41 In the argumentation of many, a Lamarckian allowance for the influence of environmental factors on inheritance is also observable in addition to Darwinism. Among the latent factors that predispose the “race” (human race) to mental illnesses, for instance, Oláh, enumerates: Over-reproduction, atavism, breeding disturbances [fajtenyésztési zavarok], marriages characterized by repugnance repeated over several generations, years of starvation following bad harvest, all may be distant causes of mental illnesses. More immediate causes include all those circumstances that formed factors damaging the ancestors’ health: insufficient diet, overstressed work, chronic diseases, chronic poisoning, … most of all, chronic alcoholic poisoning, furthermore, the bodily infection of ancestors, their mental life, protracted sadness, futile life struggle, great disappointments and passions, etc.42

We see in these and other quotes by psychiatrists elements of contemporary eugenic thinking and discourses, widely used biological and degenerationist arguments, in most cases however without the explicit mention of or reference to eugenics. Oláh, for instance, identifies a close and undeniable relation between mental illnesses and the damaging influence of alcohol, syphilis, and adds “breeding mistakes of the ‘genus homo sapiens’” in which cases “state intervention would result in positive achievements with predictable costs, investments and interests.” He alluded to the widespread notion that “we breed dogs and horses, while patiently watch the decline of our own race, which is confirmed from the side of mental pathology” (51). Oláh mused over questions of reproduction, the preservation of the race or breeding, “with their hundred moral, philosophical, individual rights, and natural scientific implications.” While Oláh believed that “the already stunted, … weak products of a mistaken breeding system can still be improved,” he added pessimistically that if “both wedded parties mutually cumulate the factors of tainted heredity on their own sides,”

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they may give rise to “increasingly degenerate offspring who, with their predispositions and feelings, will occupy a place outside of society, will be asocial, and even turn against society: anti-social” (58). Concerning syphilitic paralysis progressiva, since it was understood to be inherited by the child at birth, and since experts regarded the disease as nontransferrable to the offspring only after three years of recovery from it by the adults, Oláh would have found it reasonable to rely on medical expert opinion and make marriage between infected people dependent on the lapse of time after treatment (57). Oláh, however, warned that the biological laws of mental and physical development of the human race were still uncertain and, in regard to the improvement of the human race, different powers and needs prevailed compared to those in animal breeding: “It is still too early to wish to correct nature” (59, 65). What Oláh found possible on the part of the psychiatrist was an attempt to avoid the “gravest breeding mistakes” with the help of a medical evaluation of the health records of those who wished to marry, to make the marriage of incurable imbeciles, epileptics, “anthropologically degenerate people”—especially when both parties are afflicted—“more difficult,” while the marriage between young and healthy individuals would be “more easy” to attain. “Going further than this would not be possible without bringing the repugnant aspects of artificial breeding into the bonds of marriage.” Even in marriage, he contended, nature can have her redeeming influence through attraction and choice, and through the positive influence a healthy party may have on the spouse (59, 65). The only “intervention from a psychiatric perspective” that he found necessary on the part of the doctor was when one of the marrying parties was suffering from a mental disorder that was not recognised by his or her environment, such as imbecility with ethical defects, epileptic or hystero-epileptic mental disorders, grave neurasthenia, or paralytic patient in the remission phase, etc. (65–66). He also mentioned as a “curiosity” Bleuler’s idea of minor surgical intervention in “epileptics, idiots, and alcoholics” to stop the reproduction of degeneration, and the fact that in the United States there were already serious considerations given to the introduction of castration in such cases (62). Informed by Darwinism, degenerationist and eugenic thinking, at the 1902 Second National Alienist Congress Lechner claimed that degeneration and certain pathological dispositions were “the tools” of natural selection and that nature’s aim to “muster out the weak and unfit” served the interest of the majority in the end. Lechner was also cautious

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and somewhat optimistic about the degenerative effects of society: “But nature set regeneration against degeneration. With the mixing of blood, … the (strengthening) of new abilities and their transmittal, the decaying genus may flourish again.”43 The key to regeneration, according to him and most of his psychiatrist colleagues, was prophylaxis as defined by the expert psychiatrist. In order to fight degeneration, Lechner suggested a “hygiene of reproduction”: “the expedient manipulation of marriage, upbringing, and social life.” Rather than siding with the prohibition of reproduction in cases of people whose offspring endangers the health of society, Lechner claimed that the doctor’s duty was to implement the “hygiene of reproduction” via “educating the public,” “spreading repugnance against damaging marriages” and enlightening people about “imprudent connubiality” via the “increased influence of family doctors experienced in psychiatry.” It is the psychiatrically-informed doctor’s job to prevent “love’s embrace” from becoming the undesired channel for the transmission of “pathological irritation, violent emotions or alcohol-induced excitements.”44 Elements of eugenic thinking therefore can be found in Hungarian psychiatric discourses of the time, medical professionals were vocal concerning issues of public health that were often cast in the language of eugenics, and psychiatrists were active in movements around social issues that became target in European eugenics in the first decades of the new century, such as the temperance movement for instance. But there was no formal eugenics movement or society organised and designated as such before the beginning of the First World War in Hungary (the Race Hygiene Inter-Association Committee [Egyesületközi Fajegészségügyi Bizottság] set up in 1914, its activities just to be suspended very soon due to the war).45 Furthermore, psychiatrists used the concepts of “race” and “race breeding” in the sense of “human race” and not in any racialist and ethno-centric meaning. After elaborating on the above topics in a chapter entitled “Social mental health care,” Oláh continued with a chapter on “Individual protective mental health care.” After discussing the choice of the right spouse as part of “individual prophylaxis,” he elaborated on issues such as: the degenerative result of procreation under the influence of alcohol, the impact of lues on the mother, and the offsprings of morphinists.46 He believed that “individual protective health care” had the greatest role in childhood and adolescence, to which he designated a separate chapter. Concerning the “psychiatric prophylaxis of adult people, that is

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constituted of psycho-hygiene built on the foundations of modern mental health care” (68). In the fight against mental disorders, protecting children’s mental health was crucial in Oláh’s mind. He thought that the “psychiatric control of child rearing, or the prevalence of mental health points of view in education” were essential, with the help of school doctors trained in mental health but more particularly in children’s psycho-hygiene. The increasing application of experimental psychological examinations in schools would also be greatly advantageous, Oláh believed and talked about Pál Ranschburg’s experiments and findings concerning children’s learning capabilities, etc. with hopes (60, 84, 85).47

Shell Shock and Traumatic Neurosis48 The gravest psychic and bodily symptoms occur following each other or in a combined way ... But it is the psyche that undergoes the greatest suffering. The bodily exhausted, often starved and maximally tired soldier finds himself in the middle of the most murderous battle, where he only sees around himself human death and enormous destruction. The unending strife for life ... makes such destructions in his soul with which only the strongest can compete, the weaker falls out and leaves the struggle physically and mentally broken.49

Another area where psychiatry’s expanded social and political function became visible was related to the Great War and the enigmatic affliction with which many of the soldiers returned from the frontline: shell shock.50 A wide range of baffling and incapacitating symptoms were observed in these soldiers: tics, trembling, functional paralysis, (hysterical) inability to walk or stand, walking with contracted muscles or on tiptoes, hysterical blindness and deafness, speech disorders ranging from stuttering to mutism, confusion, extreme anxiety, headaches, amnesia, depression, unexplained cramps, fainting and vomiting, hiccupping, increased sweating, delirium, forgetfulness, etc.51 The first modern, highly technologised warfare resulted in the mass slaughter of soldiers on the battlefields and also inflicted much suffering, losses, casualties and distress for the civil population at home. The war was thus a massive traumatic experience for all involved.

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Shell shock or war neurosis was seemingly a new phenomenon that became entangled with questions of patriotism, masculinity, national versus individual interests, and social and economic consequences of the war (such as paying pension to retired shell-shock patients).52 Dominantly identified as a form of neurosis, it connected to the culturally rich notions of degeneration, nervous weakness, hysteria, neurasthenia, nervous exhaustion in the face of the new challenges of modern life and civilisation discussed above. It also provided the newly emerging psychoanalytic perspective a new arena where it could stretch its muscles and compete with success with more traditional psychiatric models and reasoning at the end of the observed period. In spite of the seeming novelty of the large-scale appearance of men suffering from war neurosis, most doctors set up a direct genealogy between war neurosis and the mid- and late-nineteenth-century notion of “railway spine” or “traumatic neurosis.” Railway spine was “the diagnosis for post-traumatic symptoms exhibited by people who experienced railway accidents (sometimes the viewer could also have a similarly traumatic experience)”.53 The phenomenon was also observed in relation to industrial and factory accidents. Thus, if unprecedented technological developments, industrialisation and the railway in particular became the emblems of nineteenth-century modernity, the price society had to pay for such progress was not insignificant and became symbolised by the disorders “railway spine” or traumatic neurosis. In the quest for understanding war neurosis, many doctors came to equate it with hysteria so famously associated with women for centuries. It was also an eminent disease form widely studied by nerve doctors in the 1880s and 1890s throughout the Western world together with hypnosis both as a therapeutic means as well as a tool to investigate the mind and different states of consciousness (discussed in Chapter 5). This intense experience with hysteria and hypnosis had provided doctors with clues when making sense of war neurosis and for many, provided an obvious genealogy for the disease. (Today the mental health condition caused by a terrifying event, such as accident, war or sexual abuse, both in the person who experienced it and the one who witnessed it, is called posttraumatic stress disorder—PTSD and understood to be psychosomatic in nature). Knowledge of and interest in the disorder’s manifestations were thus in fact deep-rooted in the modern notion of trauma and the psychiatric illness called traumatic neurosis as well as in former psychiatric

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research on hysteria, on the workings of the mind and hypnosis, and on the therapeutic uses of suggestion. War neurosis also brought about an intense debate concerning the aetiology of the disease which became very important in the history of psychiatry as well as science and medicine. The debate proceeded both in national and international arenas about the somatogenic versus the psychogenic origins of war neurosis, an opposition that had been central to thinking about the nature of mental illnesses in the history of madness and psychiatry and that flared up again with a renewed vigour. Although today the psychogenic origins of PTSD is generally accepted and some writers on shell shock project this back on their historical object of study, it is necessary to stress that the psychiatric profession was itself split over the issue at that time. For instance, the influential Hungarian neurologist, Artúr Sarbó claimed that no such thing as a common disorder of war neurosis existed (see below). Some allowed for two kinds of war neurosis: one with organic, and one with psychological aetiology. Others insisted that indeed, all cases were purely psychological in nature. What theory one subscribed to also influenced possible forms of treatment. For the historian, these documents thus reveal precisely the moments and the ways in which the disease was constructed, contested, its essence scrutinised and treatment questioned at the time. In the following, I briefly introduce the most significant approaches to war neurosis and forms of treatment characteristic in Hungarian psychiatry during the First World War by singling out the relevant work of Artúr Sarbó, Ern˝ o Jendrássik, Viktor Gonda and Sándor Ferenczi, certainly the most important representatives of the field. Artúr Sarbó and the Theory of Micro-Structural Changes The most clearly somatogenic theory was proposed by the neurologist Artúr Sarbó (1867–1943), a scientist of international fame and the founder of logopedia in Hungary.54 During the First World War, he served in the military and organised two military hospitals in Budapest for the treatment of nervous patients. At the VI. conference on military surgery in December 1914, Sarbó, director of the Váczi Street Military Hospital,55 gave clinical presentations on several of his patients and already stressed his view that the great blast that accompanied the explosion of a shell or Schrapnell caused concussion of the brain and the spinal cord and therefore the arising nervous manifestations were due to real

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changes in the organism.56 Yet, contrary to the usual cruder organic lesion visible to the eye, these he understood as very small-scale changes: bruises or minimal bleedings in the nerve tissues, which were capable of producing paralysis, but not grave enough to lead to necrosis (death of the tissue). He also differentiated it from what Charcot meant by “molecular changes” when he argued for the organic origin of functional nervous disorders (hysteria, neruasthenia) in molecular changes invisible even to the microscope. Thus, somewhere between the crude, visible organic lesion and the invisible molecular changes, Sarbó proposed what he initially called micro-organic57 changes but then, to avoid misunderstandings, switched to micro-structural changes.58 He insisted that he had ample experience with hysterical patients in peace-time and could identify “real hysterical speech disorders,” where the psychic origin could always be proved. Yet the symptoms of these soldiers were different, he contended.59 The organicist view had several followers in Europe, most prominent of them was Hermann Oppenheim who himself coined the term “traumatic neurosis” in the 1880s and he meant by it the physical lesion of the nervous system.60 Sarbó believed that the prognosis for his cases was generally good as most patients healed spontaneously. In terms of therapy, he stressed an adequately long rest for the patients.61 The doctor must leave the patients in peace, feed them well, perhaps provide luke-warm baths and sedatives and thus they would be cured in time.62 In 1916 he criticised those who believed in the hysterical nature of the condition and argued that the whole arsenal of suggestive therapies they would introduce would be of no avail, on the contrary, would be detrimental to the nervous system of the patients. Sarbó claimed to have initially tried to treat patients with faradic electric treatment as well as with hypnosis but saw no good results.63 Ern˝o Jendrássik’s Degenerationist Understanding of War Neurosis It was at the 2nd Internal Clinic of the Budapest Medical Faculty under his direction, where he used to conduct his own experiments on female hysterical patients in the 1880s and early 1890s,64 that the eminent neurologist Ern˝ o Jendrássik observed and treated over a thousand shellshock patients by the end of the war. Jendrássik noted that “the majority of the people (…) claim that their malady was caused by the air pressure due to the explosion of a shell, which air pressure pushed them to the

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ground or threw them up into the air, they lost their consciousness and by the time they regained it, their symptoms were all developed.”65 Yet he believed that most symptoms were not due to some physical trauma, but belonged to hysteria, where the hysterical phenomena were triggered by psychic traumas, which could be sudden accidents or frights, but also less intense but longer lasting psychic traumas (439).66 Yet we should not be mistaken, in Jendrássik’s case, this did not mean a “psychological” understanding of the disorder itself. Even if a psychic trauma triggered the disorder, what counted according to Jendrássik, Hungarian pope of degeneration theory67 was: disposition. War neurosis developed in people who had a hysterical disposition: when some psychic trauma affected an already predisposed nervous system. Jendrássik gave a truly organic definition: the essence of hysteria was the “more weakly developed stage of the associative nerve fibres,” hence it was the missing associative functions of the brain that was responsible for the also missing function of criticism. It also explained why hysterical people were so suggestible.68 Jendrássik’s hysteria aetiology hypothesis was shared by many Hungarian psychiatrists,69 Jendrássik’s colleague at his clinic, Ármin Weisz claimed to have treated over 1200 soldiers with traumatic neurosis at the clinic by 1918, “there was not a single symptom in this vast patient material that we have not seen in hysterical patients during peace time.”70 If suggestion therapy was so pervasive in case of hysterical patients from the 1880s on, the power of suggestion had a crucial role in Jendrássik’s treatment of soldiers. In his clinic, patients were placed in large wards, separated from each other by screens. They were not allowed to leave their beds. Visitors were not allowed to see the patients, other fellow patients were also forbidden to peek into the sequestered areas, and not even other doctors from the ward were allowed to these patients. This isolation, which Jendrássik claimed to have used very successfully for many years at his clinic, was necessary, as poorly recovering and renitente neighbours could disrupt healing, while at the same time witnessing a sudden cure behind the screen perceived as a form of “miracle” in the uninitiated eye positively affecting treatment. Slowly patients developed an interest in the discussions audible in the room, which diverted their attention so focused on their affliction, and increased their desire to communicate with others again, all of which greatly and positively affected their treatability, Jendrássik explained.71 In addition, the good reputation of the clinic also proved to be therapeutic in so far as “promising” certain cure.72

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In case of soldiers, Jendrássik added to isolation and suggestion the administration of strong faradic currents to some sensitive areas on the body (not coinciding with the location of the neurosis complaint, as that would have strengthened their false beliefs that they were suffering from some organic, physical disease).73 The electric current was “the strongest the machine is capable of sending” (441). Yet even this treatment was directly preceded by clear verbal suggestions (441). Reports by Jendrássik’s colleagues at his clinic confirm that pain was part of the treatment, even if not intended as a punitive measure. József Csiky wrote that the sudden pain caused by the application of strong faradic electric currents amounted to a sudden psychic shock capable of ceasing even the gravest paralysis or mutism.74 Ármin Weisz emphasised that patients had to be reassured that “with the strong pain we do not torture, but cure him.”75 He added that the faradic current had to be applied where it elicited the biggest pain, “but never in loco dolenti.” When the patient was prepared by suggestion, the electricity “eliciting great pain” made all “hysterical symptoms disappear in seconds: the dumb speaks, the deaf can hear, the patient lifts his paralysed limb” (125). No wonder doctors spoke of treatments at Jendrássik’s clinic as “miraculous,” which was not only perceived as such by the patients and lay people, but also surprised the doctors and filled them with great ambition.76 The strong faradic treatment worked as “Deus ex machina” in the hands of the doctor.77 Viktor Gonda’s “New Electroshock Therapy” at the Rózsahegy Hospital A third, both hailed and criticised approach to the treatment of shellshock was initiated at the Rózsahegy Special Hospital complex of the Hungarian Royal Office of Invalids [A m. kir. Rokkantügyi Hivatal rózsahegyi különleges gyógyintézete, Rózsahegy Hospital from hereafter] specialised in internal and nervous patients since January 2016 in a beautiful area lying 500 m above the sea level and surrounded by hills. Initially, it served regionally but soon all military hospitals and troops could send their patients there, primarily tuberculotic, but also nervous patients.78 Viktor Gonda was chief doctor at the nervous ward where 300 soldiers were treated with “traumatic neurosis” diagnosis, demonstrating the usual symptoms. According to Gonda, most of them had been hospitalised for months and moved from one institution to the other where they received different medications, bath and electrotherapy, but no cure was achieved. Gonda identified the cause of their disease as “grenade blast,

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cold.”79 In his publications, Gonda was little concerned with the nature of the disorder and lay emphasis instead on treatment. In the initial months, Gonda treated these patients with the “usual” electrotherapy, hydrotherapy, suggestion and hypnosis therapy, which were complemented with systematic walking exercises. With these methods they were able to achieve improvements in case of some patients, but the paraplegias (two-sided paralysis of the limbs), the hysterical deafness and blindness and ticking could not be removed. Therefore, in August 1916 Gonda enthusiastically reported on the results of a “new electroshock therapy” that he recently introduced in the hospital following an article by the German neurologist Fritz Kaufmann that year. A crucial part of Kaufmann’s treatment was the intentional pain caused by the electrotherapy (the shock lasting for between 2 to 5 min each) which was preceded by an elaborate psychological build-up to create a suggestive milieu. In the hospital, Kaufmann insisted on “the strict adherence to military forms,” used military commands and orders in the ward.80 While Gonda also laid emphasis on the suggestive aspect of the therapy, he does not seem to have gone so far as to create a military environment at the clinic. But he emphasised the suggestive impact that the healings had on other patients. He psychically prepared the patients for the treatment by carefully staging it: during the patient examination, Gonda explained to the medical student by his side that, for instance, „the patient’s ability to walk will return, especially now that such disorders can be cured by the new invention in a few minutes,” making sure that the patient clearly heard it.81 Regarding electroshock therapy, the novelty concerned the strength of the applied electric current. Since Kaufmann did not report on this, Gonda seems to have experimented with it. Concerning timing, Kaufman claimed to have used it for 2 to 5 min for each shock, Gonda also reported of a few minutes per shock but repeated many times (445). He placed one electrode to different muscles in the limb and applied faradic current, gradually increasing it until he achieved the strong contraction of the muscles. He then immediately turned the electricity off. After pausing a little and in the meantime also making strong verbal suggestion, such as: “now comes the life-giving electricity,” he suddenly reapplied electricity with double strength in order to achieve continuous muscle contraction. Due to the pain caused, the patient would scream and to avoid defending himself and removing the electrodes, the doctor’s assistant held down his arms. Gonda did not turn the electricity off after the first shouts, only

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after about half a minute, and then repeated the treatment on the other leg as well (445). The longest application of the electric current was 3– 4 min. As a result, “the patients, most of whom had been helplessly tied to bed for 6–22 months, now return to the hospital ward a few hundred meters away on their own foot” (445). Gonda added that “The patients react to their cure with the greatest happiness” (446). By the Summer of 1918, within a year Gonda claimed to have treated 3200 soldiers with traumatic neurosis, most of which allegedly cured by his treatment.82 He claimed to have gradually reduced the time of application of faradic currents and lowered their intensity, thus also removing pain from the process. No matter what caused the disorder, how long ago it began, how serious form of traumatic neurosis it took, how many hospitals the patient was treated in and with whatever treatment and result, … we have always been able to eliminate the symptoms of the disease within a few seconds.” “No-one has offered yet a more humane and versatile method. If there was one, I would happily take it up”—Gonda concluded (345–346). “The new’miraculous’ healing,” conducted at the Rózsahegy Hospital was sensationalised and received both acclaim and criticism.83 But it is not clear why it was claimed as new, given the fact that electric treatment was widely used with nervous patients at the time. Furthermore, there was not such a great divide between Gonda’s treatment and that provided at Jendrássik’s clinic. What was central to both was the suggestive milieu: from the carefully set-up ward, the inadvertent hearing of what happened to the neighbours, through actual suggestions of recovery, to the good reputation of the clinic, all moments and elements of treatment had a suggestive function. In Gonda’s words: “It is certain that during treatment the air is vibrating with the mood of the certainty of cure. This must be created by the doctor. He must take suggestion to its maximum with his complete self-devotion, tirelessly, using all his might.” (346). This is especially important in the initial phase, as once the news of healing starts spreading in the ward, treatment becomes much easier and we can manage to treat 15 -20 undressed patients at the same time in front of each other, within a couple of hours. This only has two elengedhetetlen factors: the certain and absolute belief shared by both patient and doctor in the possibility of cure. (346)

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Sándor Ferenczi and the “Discovery of the Psyche”: The Psychoanalytical Approach At the start of the war, Ferenci was immediately assigned as a doctor at the hussar regiment at Pápa. From the end of 1915, Ferenczi was moved to Budapest and became chief doctor at the nervous ward of theRoyal Mária Valéria Barrack Hospital where he first met war neurotic patients in greater number. By March 1916, he published on the types of war neurosis in Gyógyászat and in Budapesti Orvosi Újság where he elaborated on his ideas on the psychogenic aetiology of traumatic neurosis based on Freud’s hysteria theory. Using the Freudian concept of the “anxiety hysteria” (szorongásos hysteria), Ferenczi argued that this disorder, manifest for instance in the symptom of astasia-abasia (incapacity to stand or walk), emerged in people who were deeply shaken in their self-confidence and unconscious selfesteem by a psychic trauma to the point that every action and even its attempt caused severe anxiety. At the same time, motionlessness—to which they were confined by their disorder—“defended them from the conflicts of the external world and secured them relative peace, even if at the price of almost completely sacrificing their personal and social ability to act.”84 The terrible experiences and frights caused these people to unconsciously “escape from the horrible external world to the disease and into the peaceful bed.” In fact, the unconscious self defended the person even against his conscious will to move (205).85 Two years later, at the Fifth Congress of the International Psychoanalytical Association (1918)—which was originally planned to be held in Breslau but, due to circumstances of the war, eventually moved to Budapest after Ferenczi’s intervention—Ferenczi gave a talk on war neurosis. He provided a critical overview of its scholarly literature and presented a psychoanalytical perspective on the subject, again arguing for the psychological aetiology. He criticised former organic and mechanistic explanations of nervous disorders which “left the psyche out of” the discussion,86 and scourged neurologists for having disregarded Breuer and Freud’s pioneering work on the psychic basis of nervous pathology as well as the growing psychoanalytic literature on the mechanisms and disorders of psychic life in the previous two decades since the birth of psychoanalysis. He triumphantly stated that, by the end of the war, many neurologists had to accept the psyche’s role in the disorder.

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When Ferenczi set out to explain the psychoanalytic conception of traumatic neurosis, he took its genealogy back to Charcot who claimed that fright and reminiscences of it might produce physical symptoms just like hypnosis or auto-hypnosis did. Ferenczi reminded that Breuer and Freud’s first analysis of the psychic mechanisms of hysterical phenomena derived from Charcot and Janet’s clinical and experimental insights. ’Hysterical patients suffer from reminiscences ’: this first principle of psychoanalysis is in fact the continuation, deepening and generalising of the Charcotian concept of traumatic neurosis; in both we find the idea of the enduring influence of a sudden emotion... (209)

Ferenczi enlisted contemporary psychiatrists whose ideas were similar to Freudian psychoanalysis, such as Robert Gaupp, for instance, who accepted the Freudian interpretation of war neurosis as “an escape from the psychic conflicts into the illness” and who also relied on the Freudian idea that “psychic processes have an impact on the body even if they are unconscious” (210). Psychoanalysis “regarded the neurotic symptoms generally as the manifestation of unconscious desires or their reactions” (211), Ferenczi stated. Vogt or Schuster also endorsed the idea of neurosis as an escape as well as the role of the unconscious (211). Others used the notion of repression of emotions. Ferenczi praised the neurologist Max Nonne for suggesting that the hysterical symptoms were partly the reflection of a defensive and preventive mechanism we were born with, which positioned Nonne very close to the psychoanalytic understanding (216). Ferenczi claimed to see Breuer and Freud’s conversion theory (psychic influence is converted to bodily manifestation) in many approaches, the way he basically identified references to a reversion to atavistic and infantile modes of reactions in the literature with Freud’s notion of the “regressive character of neurotic symptoms,” a “return to earlier, already surpassed stages of onto- and phylogenetic development.”87 Ferenczi ended his talk with his own psychoanalytical explanation of war neurosis. The war neurotic developed an “increased self-sensitivity” due to the fact that the once or repeatedly experienced trauma “withdraws his libido and interest in [external] objects back to the self.” This withdrawal and increased self-sensitivity got manifested in hypochondriac depression, timorousness, anxiety, and a great degree of irritability and expression of anger. The extreme turn towards the self, the

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increased self-love often degenerates into real childish narcissism: the patients wish they were pampered as children, cared for and pitied. This is a regression to the childish phase of self-love. This regression is also characterized by a decrease of object-love and sexual potency. Obviously, a person with narcissistic disposition is more likely to suffer from traumatic neurosis, but no-one can be seen as entirely free of it, as the phase of narcissism is an important fixation point in everyone’s libido-development. (221)

Anxiety as a symptom is the sign that the trauma undermined the selfconfidence, especially manifest in people who were thrown off their feet and covered by an explosion, Ferenczi continued. “Characteristic disorders of movement … function as defenses against the re-living of the anxiety, they are Freudian phobias.” Compared to this group of “anxiety hysteria”, “symptoms which simply preserve the situation (the posture) at the time of the explosion are symptoms of conversion hysteria in the psychoanalytical sense”88 (222). A disorder of movement also meant a “relapse to the infantile stage of inability to walk and learning to walk.” The frequent bouts of anger amounted to the primitive form of reaction to strong authority, they were “uncoordinated emotional discharges” often detectable in infants. “Lack of discipline visible in almost all traumatic neurotic soldiers” derived from the same source. The need for spoiling and an increased irritability resulted from narcissism. “The personality of most traumatic individuals therefore matches that of spoilt, un-inhibited bad child who turned anxious due to a fright.” (222–223) Finally, Ferenczi briefly referred to dreams of anxiety in which the patients re-lived again and again the original or very similar fright. He regarded these dreams, after Freud, as the patients’ “involuntary healing experiments ”: “the patients bit by bit turn the frightening shock, which is repressed and converted to bodily symptoms, to voluntary abreaction, thus readjusting the offset balance of the psychic economy.” (224) Although Ferenczi repeatedly argued for the psychogenic aetiology of neurosis, he further specified the psychoanalytic take on this issue. He referred to Freud’s notion of an “aetiological sequence” in which disposition and the individual trauma together produced neurosis in a reciprocal relation: weak disposition and great shock achieved the same result as strong disposition and a weak trauma (213). In spite of obvious differences in approach, this introduction of “disposition” to the aetiology of war neurosis calls into mind Jendrássik’s degenerationist theory,

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where a psychic trauma only triggered an already predisposed (hysterical / degenerate) nervous system. Even if certain elements had to be discarded as irrelevant (such as the role of childhood and sexual abuse in the original hysteria interpretation), the basic tenets of Freudian psychoanalytical theory concerning the importance of traumatic experiences and their haunting memories, the attempts at their repression, the conversion of mental conflicts into bodily symptoms, the role of catharsis, abreaction, and dreams and their interpretation—all proposed in Ferenczi’s discussion above—demonstrate how this psychological interpretation offered a convincing explanation for neurosis and would serve a foundation for modern psychiatric theorising and treatment in the coming decades, making the twentieth century the century of psychoanalysis. The psychoanalytical interpretation of war neurosis could have immediately offered new ways to treat patients, but these years seem like a period of experimentation with it, rather than of widespread use. Indeed, we know that several psychoanalysts serving as doctors in the war attempted to apply the psychoanalytical method. In his 1918 lecture, Ferenczi referred to Mohr, who was claimed to have used Breuer and Freud’s cathartic method (that evolved during the treatment of Anna O. by Breuer to become the foundations of psychoanalysis, Christened as “talking cure” and “chimney-sweeping” by the patient, Anna O. herself), during which the doctor made the patient re-live the “critical scenes” and made them abreact to their emotions through re-experiencing the frightening emotions they had. The German psychoanalyst Ernst Simmel also systematically used the cathartic method in treatment and in Britain, W.H.R. Rivers was the most prominent practitioner of psycho-therapy).89 On January 24, 1916 Ferenczi informed Freud that he “analysed (allowed to free-associate)” a soldier suffering from war trauma who lay 24 h under a corpse. The analysis lasted for an hour and he learnt that during the previous years the soldier had lost his father, two brothers, and his wife “through unfaithfulness,” which made Ferenci wonder “how much of his neurosis is due to war trauma.”90 One feels the sense of disappointment and indeed, the lack of time would make the application of the psychoanalytical method impossible or at least highly difficult in wider circle of soldiers. Already claiming to have observed over 200 patients at the neurology ward that he had directed at the Barack hospital for two months, Ferenczi actually referred to his own experience in 1916 when he

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advocated “strong” electric currents he called “electric spanking,” suggestive or hypnotic influencing in the forms of “commands” or “requests,” and all forms of “education” of the patients.91 He surely would not have the conditions to conduct hours-long analytical sessions to cure people through talking at the wards, not when the splendidly efficient electric current brought miraculous results in minutes. The semi-military terms he uses (electric spanking, commands, forms of education—meaning disciplining—of the patients) demonstrate how pervasive the equation of treatment with disciplining and punishing was in the military realm and not only among German doctors. Ferenczi and Freud’s relationship in these years constitutes a uniquely important chapter in the history of psychoanalysis in Europe. As the extensive correspondence between the two men testify, during the years of the war, Ferenczi was the most important and closest psychoanalytical colleague of Freud. Ferenczi and the Hungarian capital were especially important for Freud, since Freud had great hopes to reorganise and reform the international psychoanalytic movement from Budapest after the end of the war.92 Ferenczi was capable and active. He managed to organise the Hungarian Psychoanalytic Association in 1913 with a group of prominent psychiatrists and intellectuals, including István Hollós, Lajos Lévy, Sándor Radó, Géza Róheim, Michael and Alice Bálint, Imre Hermann and also Melanie Klein.93 Those practicing or following psychoanalysis were dominantly leftist, progressive intellectuals often with Jewish background. Ferenczi was instrumental in bringing the Fifth Congress of the International Psychoanalytic Association to Budapest where he was elected the President of the Association. He also managed to secure for himself the first psychoanalytical chair in the world with the establishment of the short-lived Department and Clinic of Psychoanalysis at theedical Faculty of Budapest University in 1919 (made possible by the also short-lived Communist regime after the end of the war). Budapest thus emerged as an important centre of pluralist and progressive psychological and psychoanalytical endeavours, in spite of the fact that the ‘Christian regime,’ established in the post Trianon rump state, had lost via emigration some of its best minds in the emerging human sciences. From the almost twenty initial members—all Jews—of Ferenczi’s Hungarian Psychoanalytical Association, only about six accomplished a life career in Hungary. Others left the and established schools abroad, like Franz Alexander, who founded the Chicago Institute of Psychoanalysis or Sándor Radó the Columbia Psychoanalytical Institute.94

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In 1918 Ferenczi, perhaps too optimistically, stated in his talk at the international conference that the war and the experience with war neurotics actually led to the “discovery of the psyche” and the “posterior discovery of psychoanalysis” by neurologists.95 But why is it—Ferenczi asked—that, while so many psychiatrists use psychoanalytical (or similar) concepts and theories in connection to war neurosis, they do not seem to apply the psychoanalytical perspective in case of everyday neurosis and psychosis known in peace time? Why are they so generally critical of or openly rejecting psychoanalysis in peace time when they accept that war neurosis does not differ from general neurosis? Ferenczi clearly wanted to take the credits psychoanalysis gained in the interpretation of war neurosis to the realm of everyday neurosis and psychosis in peace time. This was a strategic attempt to extend the psychoanalytical expertise assumed to be accepted in relation to war neurosis to the wide realm of everyday neurosis and the mental hygiene of everyday life. This is part of what this chapter—and partly the book—sought to capture: the process through which psychiatry strengthened and invaded the public and the private realms through its increasingly claimed expertise in solving social problems that were related to psychiatric disorders such as nervousness, paralysis progressiva, alcoholism, crime, and poverty. In their arguments they utilised statistics, referred to the state budget, agricultural production, etc. (see Pándy, s. d.)96 and generated strong social criticism. They also became involved in social movements, like the temperance movement, and published widely on these topics in scholarly as well as more popular journals. The underlying psychiatric explanation was degeneration, which the psychiatrist set out to fight by prophylaxis and the elaboration and implementation of the hygiene of mental and general health. This extension of psychiatric expertise to social arenas and everyday life certainly demonstrates that the psychiatric profession, which was mostly concerned with setting up the first mental institutions fifty years earlier, had strengthened by the turn of the century and expanded its manifold roles and functions in society.

Notes 1. Elisabeth Lunbeck, The Psychiatric Persuasion: Knowledge, Gender, and Power in Modern America (New Jersey: Princeton University Press, 1994).

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2. Gusztáv Oláh, Az elmebetegségek orvoslása (The Cure for Mental Illnesses) (Budapest: Pfeifer Ferdinand, 1903b), 4–5. 3. Degeneration theory was first systematically described by French psychiatrists J. Moreau de Tours (1804–1884) and Augustin Morel (1809–1873), later popularised by Paul Möbius (1854–1907) and the Hungarian-born Max Nordau (1849–1923) and was widely accepted by psychiatrists by the last third of the nineteenth century. On the medical concept as well as rich social meanings of degeneration, see Daniel Pick, Faces of Degeneration: A European Disorder, c.1848–c.1918 (Cambridge: Cambridge University Press, 1989); the relevant essays in J. Edward Chamberlin and Sander L. Gilman, eds., Degeneration: The Dark Side of Progress (New York: Columbia University Press, 1985); Robert Nye, Crime, Madness, and Politics in Modern France: The Medical Concept of National Decline (Princeton, New Jersey: Princeton University Press, 1984); William F. Bynum, “Alcoholism and Degeneration in 19th Century European Medicine and Psychiatry,” British Journal of Addiction 79 (1984): 59–70. 4. Oláh (1903b), 50. 5. From this rich literature, see, for instance, Gyula Donáth, “A modern kultur-államok lakosságának testi elsatnyulása, különös tekintettel Ausztria-Magyarországra” (The Physical Degeneration of the Population in Modern Civilised States, Especially in AustriaHungary), Klinikai Füzetek (Clinical Papers) 10 (1894): 215– 234; Jakab Salgó, “A szellemi munka hygieniája” (The Hygiene of Mental Work), Az Egészség (Health) 10 (1896b): 211; László Epstein, “A gyakorló orvos feladata az elmegyógyászat terén” (The Tasks of the Practising Doctor in the Field of Psychiatry), Gyógyászat (Medicine) 43 (1903b): 676–680; Jakab Salgó, “Az elmebetegségek prophylaxisa” (The Prophylactics of Mental Disorders), Budapesti Orvosi Újság (Budapest Medical Journal) 1 (1903a): 487; László Epstein, “Az alkoholizmus társadalmi szempontból” (Alcoholism from the Social Perspective), Az Alkoholizmus (Alcoholism) 4 (1908a): 53; László Epstein, “Az öröklésr˝ ol” (On Inheritance), Természettudományi Közlöny (Natural Scientific News) 40 (1908b): 405; Jakab Salgó, “Az ideg- és elmebántalmak társadalmi okai” (The Social Causes of Nervous and Mental Disorders) Budapesti Orvosi Újság (Budapest Medical Journal) (1910): 5, 17; and Oláh (1903b).

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6. Károly Lechner (1850–1922) was a mental pathologist, chief doctor of the Schwartzer private mental asylum, later became the director of the Angyalföld National Mental Institution. He was an important proponent of reflex-theory. 7. Károly Lechner, “Az elmebetegkezelés újabb elvei” (The Novel Principles of the Treatment of Mental Patients), in Az 1902. évi október 26-án és 27-én Budapesten tartott Második Országos Elmeorvosi Értekezlet munkálatai (Proceedings of the Second National Alienist Congress, Held in Budapest, on the 26th and 27th October 1902), ed. László Epstein (Budapest: Schmidl Sándor Könyvnyomdája, 1903), 118. 8. Mór Kende, “A tabes aetiológiája” (The Aetiology of Tabes) Klinikai Füzetek (Clinical Papers) 12 (1898): 3. 9. László Epstein, “Az elmebetegség veszedelme és az ellene való védekezések” (The Danger of Mental Illness and the Ways of Countering It), Orvosi Hetilap (Medical Weekly) 39 (1899): 473. 10. Jakab Salgó, A szellemi élet hygienája (The Hygiene of Mental Life) (Budapest: Franklin Társulat, 1905a), 124. 11. Salgó (1905a), 5–29, 122–130. 12. Ferenc Schwartzer, A lelki betegségek általános kór- és gyógytana, törvényszéki lélektannal (The General Pathology and Treatment of Psychic Disorders, with Forensic Psychology) (Budapest: Lauffler és Stolp, 1858). 13. See Károly Laufenauer, “Neurasthenia,” in A belgyógyászat kézikönyve (Handbook of Internal Medicine), Vol. 6., ed. Árpád Bókay, Károly Kétli and Frigyes Korányi (Budapest: MOKT, 1899b), 1075–1113. 14. From among the numerous works, see Jakab Fischer, “A neurasthenia (idegrenyheség)” (Neurasthenia), Klinikai Füzetek (Clinical Papers) 13 (1892): 395–419; Artúr Sarbó, “A heveny idegkimerülésr˝ ol” (On Acute Nervous Exhaustion) Gyógyászat (Medicine) 1 (1894): 1–2; 2 (1894): 13–14; Endre Takács, “A neruastheniáról” (On Neurathenia), Klinikai Füzetek (Clinical Papers) 1 (1895): 3–33; Gyula Donáth, “A neurasthéniának elkülönítése a hysteria és a dementia paralyticától” (The Differentiation of Neurasthenia from Hysteria and Dementia Paralytica) Klinikai Füzetek (Clinical Papers) 5 (1895): 105–115; Károly Schaffer, “Az agykimerülésr˝ ol (cerebrasthenia) és ennek a terjed˝ o h˝ udéses elmezavarhoz való viszonyáról” (On Cerebrasthenia and

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Its Relationship with Paralysis Progressiva) Klinikai Füzetek (Clinical Papers) 9 (1896): 1–26. 15. Ern˝ o Moravcsik, “A századvégi degeneratióról,” (On Degeneration at the End of the Century), Huszadik Század (Twentieth Century) 1 (1900): 13–25. 16. István Hollós, Adatok a paralysis progressivához Magyarországon (Data on Paralysis Progressiva in Hungary) (Budapest, 1903), 14. 17. Hollós (1903), 4, 20. 18. Oláh (1903b), 57. 19. László Benedek, “A paralysis progressiva aetiologiájáról” (On the Aetiology of Paralysis Progressiva), Közlés a Kolozsvári F. J. Tudomány Egyetem Elme- és Ideggyógyászati Klinikájáról (Publications of the Mental and Neurological Ward of the Kolozsvári F. J. University of Sciences) 38, no. 2 (1913): 243. 20. Epstein (1899), 499–500. 21. Hollós (1903), 16–17. 22. Salgó (1905a), 138–140. 23. Epstein (1899), 513. 24. István Hollós, Alkohol és agym˝ uködés (Alcohol and Cerebration) (Budapest: Alkoholellenes Könyvek Könyvtára, 1909b), 12–14. 25. From the rich literature, see for instance, Antal Székely, “Az alkohol hatása az utódokra” (The Influence of Alcohol on the Offsprings), Természettudományi Közlöny (Natural Scientific News) 21 (1889): 395; Gyula Csillag, “Az iszákosság elleni küzdelem” (Fight Against Alcoholism), Az Egészség (Health) 9 (1895a): 211; Gyula Csillag, “Az iszákosság elhárítása” (The Prevention of Alcoholism), Természettudományi Közlöny (Natural Scientific News) 27, no. 305 (1895b): 378; Mór Kende, “Az alkoholismus, különös tekintettel a gyermek idegrendszerére” (Alcoholism, with Special Attention to Children’s Nervous System), Klinikai Füzetek (Clinical Papers) 12 (1899): 1–27; Gyula Grósz, “A gyermekek alkoholismusáról” (On Children’s Alcoholism), Klinikai Füzetek (Clinical Papers) 12 (1899): 31–42; Gyula Csillag, A gyermekek alkoholizmusa elleni védekezés törvényhozási és társadalmi szempontból (The Prevention of Children’s Alcoholism from the Perspectives of Legislation and Society). Különlenyomat az “Orvosi Hetilap”-ból (Offprint from the “Medical Weekly”). (Budapest: Pesti Lloyd-Társulat Könyvnyomdája, 1899); Fülöp Stein, “Az alkoholizmus elleni védekezésr˝ ol” (On the Prevention

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of Alcoholism), Természettudományi Közlöny (Natural Scientific News) 33 (1901): 636; Sándor Ferenczi, “A szesz” (Alcohol), in A pszichoanalízis felé. Fiatalkori írások 1897–1908 (Towards Psychoanalysis. Early Writings, 1897–1908) (Budapest: Osiris, 1999), 161–163, also published in: Jövend˝o (Future) 10 (1903), 56–57; Bódog Feldmann, “A szeszes italok és az iszákosság elleni küzdelem” (Spirits and the Fight against Alcoholism), Természettudományi Közlöny (Natural Scientific News) 35 (1903): 116; József Madzsar, “A szeszes italok hatása az utódokra” (The Influence of Spirits on the Offsprings), Az Alkoholizmus (Alcoholism) 1 (1905): 33; Fülöp Stein, “Alkohol és munkaképesség” (Alcohol and Capacity for Work), Az Alkoholizmus (Alcoholism) 1 (1905): 53; Imre Dóczi, “Az alkohol befolyása a faj életére és fejl˝ odésére” (The Influence of Alcohol on the Life and Development of the Race), Az Alkoholizmus (Alcoholism) 2 (1906): 134; Fülöp Stein, “Az alkoholkérdés Magyarországon” (The Alcohol Question in Hungary), Orvosi Hetilap (Medical Weekly) 50 (1906a): 70; Imre Dóczi, “Az alkoholélvezet és élettartam” (Alcohol Consumption and Life Expectancy), Az Alkoholizmus (Alcoholism) 3 (1907): 1; Imre Dóczi, “Az alkohol befolyása a faj életére és fejl˝ odésére” (The Influence of Alcohol on the Life and Development of the Race), Közegészségügy (Public Health Care) 1 (1908): 112. 26. István Hollós, “Good Templars páholy az elmegyógyítóintézetekben” (Good Templars in Mental Institutions), Az Alkoholizmus (Alcoholism) 2 (1906): 115; Sándor Ferenczi, “A szesz” (Alcohol), A pszichoanalízis felé. Fiatalkori írások 1897–1908 (Towards Psychoanalysis. Early Writings, 1897–1908) (Budapest: Osiris, 1999), 162–163; Gyula Donáth, Donáth Gyula élete és munkája. Önéletrajz (The Life of Gyula Donáth. Autobiography) (Budapest: Horizont Könyvkiadó, 1940), 34–38. Later Stein was sympathetic with and Hollós active in the Hungarian psychoanalytic movement. 27. See Fülöp Stein, Jelentés a X. Nemzetközi Alkoholizmus Elleni Kongresszusról (Report on the X. International Anti-Alcoholism Congress) (Budapest: 1906b). 28. Donáth was the founding editor-in-chief and publisher of Klinikai Füzetek (Clinical Papers) starting in 1891. He was born in 1849, studied at the Viennese Medical Faculty under several distinguished professors: the Hungarian-born anatomist Hyrtl, the Berlin-born

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Jewish physiologist Brücke, and the internists Skoda and Oppolzer. In 1874, Donáth became the head of the laboratory at the Chemistry Department of the University of Graz. In 1877, he became docent in physico-chemistry. He returned to Hungary and practiced in Baja between 1879 and 1882. In 1882, he studied with Carl Westphal at his nervous and mental clinic in Berlin for a year. Then he worked at Helmholtz’s physics and Virchow’s gross anatomy laboratories. Subsequently, he also spent six weeks at Charcot’s clinic in Paris. After returning home, he worked at a clinic for poor nervous patients in Pest, from which he resigned in 1893 to set up a nerve-clinic at Saint Roch Hospital (where the first Röntgen laboratory in the country was established under his direction). He became a private doctor of neurology in the Budapest Medical Faculty in 1893 and the head of the nerveclinic of Saint Stephen Hospital in 1902. He studied epilepsy and used a salt-solution (“nátrium nucleinicum”) to produce fevers, which by 1909 had been somewhat successful in treating paralysis progressiva. See Donáth (1940), 3–34. 29. Lechner (1903), 119. 30. Donáth (1940), 38. 31. Epstein (1899), 499–500. 32. Oláh (1903b), 53. 33. See Ern˝ o Moravcsik, “A b˝ untettes elmebetegek elhelyezése és ápolása” (The Placement and Care for Criminal Mental Patients), in Az 1900. évi október 28–29-én Budapesten tartott Els˝o Országos Elmeorvosi Értekezlet munkálatai (Proceedings of the First National Alienist Congress, Held in Budapest, on the 28th and 29th October 1900), ed. László Epstein (Budapest: Pallas, 1901), 102. See also Ern˝ o Moravcsik, “A degeneratív tünetek jelent˝ osége a b˝ unösségi hajlamnál” (The Importance of Degenerative Signs in Criminal Dispositions), Orvosi Hetilap (Medical Weekly) 2 (1891): 13–17. 34. He quoted the American doctor Dudgale’s calculations according to which: “one single crapulous woman originated 709 degenerates in the course of 75 years. At least 471 out of the 709 (the rest were untraceable) were a burden for the state as beggars, prostitutes, criminals, the insane, or people unable to work. Thus, in the given period of 75 years, that single crapulous woman cost the treasury 6 million crowns.” Lechner (1903), 119.

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35. See: Az Országos Alkoholellenes Egyesület céljai és törekvései (The Goals and Purposes of the National Anti-Alcohol Association), quoted in: Hollós (1909b), i. 36. Oláh (1903b), 52. 37. Ibid., 53; Hollós (1909b), i. 38. Oláh (1903b), 56. 39. Lechner (1903), 117. 40. Epstein (1899), 473. 41. Ibid., 486. 42. Oláh (1903b), 50. 43. Lechner (1903), 117. 44. Ibid. 45. Here I disagree with Marius Turda who greatly inflated the meaning of eugenics in his book on the topic in the Hungarian context, for instance, quoting and referring to many people as “eugenicists” without evidence for them having been eugenicists. While it is a mostly useful sourcebook, I cannot agree with his main suggestion that Hungarian eugenics as such was at the forefront of European developments. I also have problems with the selective nature of his book: while there are some references to psychiatry and its practitioners, there is no sustained and comprehensive treatment of this field which was otherwise so relevant to eugenics he studies. See Marius Turda, Eugenics and Nation in Early 20th Century Hungary (London: Palgrave Macmillan, 2014). 46. Oláh (1903b), 66–67. 47. See also: Sándor Szana, “A züllött gyermekek psychopathologiája és socialhygieniája” (The Psychopathology and Social Hygiene of Depraved Children), in Az 1911. évi október hó 29-én és 30-án Budapesten tartott VI. Országos Elmeorvosi Értekezlet Munkálatai (Proceedings of the Sixth National Alienist Congress, Held in Budapest, on the 29th and 30th October 1911), ed. Károly Hudovernig (Budapest: Pesti Könyvnyomda, 1912), 147–179; and Pál Ranschburg, “A pathologiás alktatúak züllöttsége. A gyermekkori züllöttség psychopathiája és társadalmi hygieneje” (The Depraved State of Those with a Pathological Disposition), in Az 1911. évi október hó 29-én és 30-án Budapesten tartott VI. Országos Elmeorvosi Értekezlet Munkálatai (Proceedings of the Sixth National Alienist Congress, Held in Budapest, on the 29th and 30th

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October 1911), ed. Károly Hudovernig (Budapest: Pesti Könyvnyomda, 1912), 180–187. 48. This is just a brief treatment of the topic here, as a much longer and comprehensive chapter on shell-shock will be part of my second book on hysteria, hypnosis and suggestion in Hungary. 49. Ármin Weisz, “A traumás neurosisról” (On Traumatic Neurosis), Orvosi Hetilap (Medical Weekly) 62, no. 10 (1918): 124. 50. Only a few studies have been written on the topic in Hungary. See Ferenc Pisztora, “Az els˝ o világháború neurózisai” (Neuroses of the First World War) Orvosi Hetilap (Medical Weekly) 126, no. 14 (1985): 855–861; Ferenc Pisztora, “Az els˝ o világháború neurózisai” (Neuroses of the First World War), in Háború és orvoslás. Az I. világháború katonaegészségügye, annak néhány el˝ozménye és utóélete (War and Medicine. The Military Medicine of the First World War, Its Predecessors and Afterlives), ed. Károly Kapronczay (Budapest: Magyar Orvostörténelmi Társaság, 2015), 121–129; Ferenc Er˝ os, “Kínzás vagy gyógyítás? Pszichiátria és pszichoanalízis az els˝ o világháborúban” (Torture or therapy? Uses of Psychiatry and Psychoanalysis in the First World War), Kaleidoscope 5, no. 8 (2014): 33–58; András Sándor, “Háborús traumák az els˝ o világháborúban I” (War Traumas in the First World War), Els˝o Század (First Century) 14, no. 3 (2015): 59–85. 51. Ern˝ o Jendrássik, “A háborús neurosisról” (On War Neurosis), Budapesti Orvosi Újság (Budapest Medical Newspaper) 12 (1916a): 93. 52. Concerning its vast Western scholarship, see, for instance: Ben Shephard, A War of Nerves: Soldiers and Psychiatrists in the Twentieth Century (London: Jonathan Cape, 2000); Paul F. Lerner, Hysterical Men. War, Psychiatry, and the Politics of Trauma in Germany, 1890–1930 (Ithaca: Cornell University Press, 2003). On war, trauma and psychiatry in Central Europe, see Hofer, Hans − Georg, Nervenschwäche und Krieg. Modernitätskritik und Krisenbewältigung in der österreichischen Psychiatrie. (Wien – Köln – Weimar: Böhlau Verlag, 2004) and Hofer, Hans-Georg, Prüll, Cay-Rüdiger and Eckart, Wolfgang U., eds., War, Trauma and Medicine in Germany and Central Europe (1914–1939) (Freiburg: Centaurus Verlag, 2011). 53. József Csiky, “A traumas neurosisról. Közlemény a királyi magyar tudományos egyetem II. számú belklinikájáról” (On Traumatic

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Neurosis. Communication from Internal Clinic II of the Royal University of Sciences). Orvosi Hetilap (Medical Weekly) 60, no. 19 (1916): 244. It is mentioned in almost all scholarly studies on the topic. 54. Sarbó got his medical degree in Budapest in 1891, a student of Károly Laufenauer, and then studied for half a year at Charcot’s clinic in Paris (focusing on hysteria), then with Weigert in Frankfurt am Main, half a year with Jackson in London and half a year with Frenkel in Berlin. As a neurologist in Budapest, he worked at Laufenauer’s clinic, first on hysteria then due to Laufeauer’s influence, more on organically based diseases through anatomical and histological studies. See: Károly Kapronczay, “Sarbó Artúr 1867–1943”. Orvosi Hetilap (Medical Weekly) 118, no. 16 (1977): 939–941. On his life and work, see also: Gusztáv Bárczi, “Professor Sarbó Artúr emléke” (The Memory of Professor Artúr Sarbó). Magyar Gyógypedagógiai Tanárok Közlönye (Communications of Hungarian Teachers of Special Education) 5 (1943): 170–171; Anna Gordosné Szabó, “A magyar gyógypedagógia logopédia öröksége a XX. sz. közepén. II. Sarbó Artúr” (The Speech Therapy-Related Heritage of Hungarian Special Education at the Middle of the 20th Century, II. Artúr Sarbó), Gyógypedagógiai Szemle (Special Education Review) 2 (1993): 94–100; István Subosits & Viktor Göllesz, Emlékezés Sarbó Artúrra (Remembering Artúr Sarbó), Ideggyógyászati Szemle (Neurological Review) 7–8 (1993): 279–280; Endréné Réthy, “Sarbó Artúr és a kisgyermekkori beszédfejl˝ odés és -fejlesztés elmélete a századfordulón” (Artúr Sarbó and the Theory of Children’s Speech Development and Amelioration at the Turn of the Century), Gyógypedagógiai Szemle (Special Education Review) 23, no. 1 (1995): 34–39. 55. By 1916, he published his papers from the Military Hospital of István Street and from the Neurological Ward of the Budapest Szent István Hospital. 56. Artur Sarbó, “A gránát- és shrapnell-robbanás okozta ú. n.” idegchock “-ról” (On the So-Called’Nervous Shock’ Caused by Granade and Shrapnel Explosions), Orvosi Hetilap (Medical Weekly) 59, no. 4 (1915): 45. 57. Ibid., 47. 58. Artúr Sarbó, “A gránát- és srapnellrobbanás okozta siketnémaság és kóroktana” (The Aetilogy of Deafness and Muteness caused

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by Granade and Shrapnel Explosions), Orvosi Hetilap (Medical Weekly) 60, no. 15–16 (1916): 181–184, 198–201. 181. 59. Sarbó (1916), 181, 200. 60. On Oppenheim, see Lerner (2003). 61. Sarbó (1915), 48. 62. Sarbó (1916), 200. 63. Ibid., 200–201. 64. See Chapter 5. 65. Ern˝ o Jendrássik, “Néhány megjegyzés a háborús neurosis tanához” (Some Notes on the Theory of War Neurosis), Orvosi Hetilap (Medical Weekly) 60, no. 33 (1916b): 439. 66 See also: Ern˝ o Jendrássik, “A háborús neurosis tanához. A hysteria és neurasthenia theoriája” (On the Theory of War Neurosis. The Theory of Hysteria and Neurasthenia), Orvosi Hetilap (Medical Weekly) 62, no. 30 (1918): 399. 67. He was the most prominent and vocal supporter of the degeneration theory who even proposed his “heredodegeneration” theory to account for the hereditarian nature of different nervous and muscular diseases among others. See Ern˝ o Jendrássik, “Az átörökl˝ od˝ o idegbajok” (Inheritable Neurological Afflictions), in A belgyógyászat kézikönyve (Handbook of Internal Medicine), Vol. 6., ed. Árpád Bókay, Károly Kétli and Frigyes Korányi (Budapest: MOKT, 1899), 994–1018. 68. Jendrássik (1918), 400–401. 69. See his colleagues at the clinic, Ármin Weisz, József Csiky, but also another influential clinician, Ern˝ o Moravcsik, “A háború psychosisairól” (On War Psychosis), Budapesti Orvosi Újság (Budapest Medical Newspaper), 17 (1916): 132–133. 70. Weisz (1918), 123. 71. Jendrássik (1916b), 440. 72. Weisz (1918), 125. 73. Jendrássik (1916b), 440. 74. Csiky (1916), 245. 75. Weisz (1918), 126. 76. Csiky (1916), 245. 77. Weisz (1918), 125. 78. Miklós Róth, “A m. kir. Rokkantügyi Hivatal rózsahegyi különleges gyógyintézete” (The Rózsahegy Special Therapeutic Institute

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of the Hungarian Royal Authority of the Disabled), Orvosi Hetilap (Medical Weekly) 60 (1916): 387. 79. Viktor Gonda, “A háború okozta ‘traumás neurosis’ tüneteinek gyors gyógyítása” (Fast Cure for the Symptoms of ‘Traumatic Neurosis’ Caused by the War), Orvosi Hetilap 60, no. 33 (1916): 445–446. 80. Shephard (2000), 100. 81. Gonda (1916), 445. 82. Viktor Gonda, “A háború okozta traumás neurosis gyógyítása” (Curing Traumatic Neurosis Caused by the War), Orvosi Hetilap (Medical Weekly) 62, no. 24–26 (1918): 315–319, 345–347, 356–358, see 315. 83. An article in the daily Magyarország (Hungary) referred to medical opinion acknowledging the successes of electrotherapy though warning of potential dangers and the fact that that not all cases of war neurosis could be treated with this method. Magyarország (Hungary), “A villamos csodagyógymód halált is okozhat. Moravcsik tanár nyilatkozata” (The Miraculous Electric Healing Technique May Cause Death. Professor Moravcsik’s Announcement), November 10, 1916, 8–9. 84. Sándor Ferenczi, “A háborús neurosis néhány typusa” (Types of War Neurosis), Budapesti Orvosi Újság (Budapest Medical Newspaper) 26 (1916a): 205, see also Sándor Ferenczi, “El˝ ozetes megjegyzések a háborús neurosis néhány typusáról” (Preliminary Notes on Certain Types of War Neurosis), Gyógyászat (Medicine) 11, 14, 18 (1916b): 124–125, 160–161, 210–211. 85. According to the psychoanalytical interpretation Ferenczi offered, the hysterical symptoms were the exaggeration of the normal expressive motions, or the symbolic representation of the psychotraumatic situation. Ferenczi (1916a) 205. 86. Ferenczi Sándor: “A háborús neurózisok pszichoanalízise” (The Psychoanalysis of War Neuroses), in: Lelki problémák a pszichoanalízis tükrében. Válogatás Ferenczi Sándor m˝ uveib˝ol (Psychological Problems from the Point of View of Psychoanalysis. Selected Works of Sándor Ferenczi), ed. Adorján Linczényi (Budapest: Magvet˝ o, 1982), 199–225, 200. 87. Ibid., 216–217. Ferenczi regarded some of these and other “pathological reactions” as forms of atavism, or a “return to ancient modes of reaction.” Ibid., 224.

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88. He differentiated two groups of traumatic neuroses: anxiety hysteria and conversion hysteria. 89. Ferenczi (1982). On psychoanalysis and shell-shock especially in Germanic Central Europe, see Lerner (2003), 163–189. 90. Ernst Falzeder and Eva Brabant, eds., The Correspondence of Sigmund Freud and Sándor Ferenczi, Volume 2, 1914–1919 (Cambridge, Mass.: The Belknap Press of Harvard University Press, 1996), 107–108. 91. Ferenczi (1916a), 205. 92. See Er˝ os (2014). 93. György Hidas, “Psychoanalysis in Hungary in the Era of Communism and Postcommunism,” Psychoanalytic Inquiry 17 (1997): 486–497. 94. Hidas (1997), 486. 95. Ferenczi (1982), 212. 96. See Kálmán Pándy, Népb˝ unök és a szeszivás (National Sins and Alcohol Consumption) (The author’s own publication, uncertain date).

CHAPTER 9

Conclusion

This book outlines the history of Hungarian psychiatry through the end of the First World War. With a combination of social and institutional history of psychiatric professionalisation, the intellectual history of shifting conceptions of mental illness and the micro-historical analysis of institutional practices and the doctor–patient relationship, I attempted to give a coherent narrative from which the model of Hungarian psychiatric history emerges. While further study is necessary to give a more refined picture of different aspects of Hungarian psychiatry, this model suggests idiosyncratic features that distinguish it from other European national psychiatries. In terms of the institutionalisation of psychiatry, these differences concern timing, periodisation and magnitude. Custodialism marking the prehistory of psychiatry appeared on a small scale in Hungary until the middle of the nineteenth century, while the early custodial lunatic asylum phase characteristic in Western countries is clearly non-existent in the Hungarian Kingdom. The first viable lunatic asylum established by Ferencz Schwartzer in 1850 (after Jen˝ o Pólya’s nonviable initiation a decade earlier) appeared at a time when the reform of the custodial asylum was largely over and the therapeutic asylum already had an almost one-half century history in Italy, France, England and some states in the German

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 E. Lafferton, Hungarian Psychiatry, Society and Politics in the Long Nineteenth Century, Mental Health in Historical Perspective, https://doi.org/10.1007/978-3-030-85706-6_9

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world. This is not simply a delay, but rather a complete lack of a phase compared to general European trends of psychiatric institutionalisation. Concerning the quality of care in a country possessing only a few healing institutions and characterised with generally low access to physicians, care for the insane was primarily the responsibility of the family and the local village or parish community until the middle of the nineteenth century (and even beyond). With a strong tradition of folk medicine and home cures, there were a variety of unorthodox healers and the clergy that generally administered to the soul and the body of the insane, rather than the doctor. The wealthiest and those living in towns had a better chance to see a doctor who would mostly provide traditional treatments to the body (medications and regimen, bleeding and purging) based on old medical wisdom and with little potential to cure. In Hungary, one cannot speak about a monopolisation of the care for the insane by the church. Although from the second part of the eighteenth century a few hospitals run by Catholic healing orders provided care for the insane, until the 1860s–1880s, the number of patients in these institution was small. At the same time, the continuous operation of these hospitals under religious auspices throughout the observed period suggests two things. On the one hand, the church retained its historic role of taking care of those in the most desperate situation, such as the poor and the incurable insane. On the other hand, these hospitals took part in a division of function between psychiatric institutions by serving to ease overcrowding at large mental asylums and hospital psychiatric wards. By the end of the nineteenth century, the Eger Hospital of the Hospitaller Order grew into the country’s number one dumping ward for the most hopeless cases. That psychiatry found ways co-operate with these religious orders is also demonstrated by the Lipótmez˝ o director Gyula Niedermann’s decision in 1893 to invite the Sisters of the Hospitaller Order to the public asylum in order to improve the quality of nursing care. State initiation of custodial care appeared from the second part of the eighteenth century within the contexts of general public health and hospital care provision strongly connected to policies developed for the poor, but these initiations achieved little until the middle of the nineteenth century. With mutual health and hospital care established first within imperial boundaries in the absolutist period, public health care became more systematically organised in the Austro-Hungarian Empire with a strong concern for poor patient care. Connected to an energetic

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institutionalisation initiated by the state in the medical sphere from the 1860s (coinciding with nation-building and modernisation), large public lunatic asylums and hospital psychiatric wards were built for the treatment of mental patients. In spite of this, the general hospitalisation of mental patients in psychiatric institutions in Hungary remained remarkably low in comparison with other Western European countries throughout the observed period. Although the Schwartzer asylum was a private enterprise highly influential in Hungarian psychiatry, private provision for the insane in mental institutions did not become a significant pattern in Hungary until the turn of the century and beyond. The spectacular mushrooming of nervous sanatoriums around 1900 was the entrepreneurial response to the “age of nervousness.” These institutions, however, generally excluded mental patients and catered to middle and upper-class clients. Other private initiatives in specialised fields, such as the care for epileptics, “imbeciles” and “idiots,” were far smaller in number and less successful. In many Western countries during the decades that preceded and followed the opening of the Schwartzer lunatic asylum in 1850, the competence of the medical—and more specifically of the strengthening psychiatric—profession in treating the insane was seriously contested. Psychiatry’s gradual appropriation of the interpretation of madness as well as the treatment and care for the insane was intensified with battles on different fronts, between physicians, laymen and representatives of the church. Characteristically, but not exclusively, these battles were fought between physicians and laymen in England, early alienists and the Catholic orders in France, and somatically oriented psychiatrists and psychologically oriented academic philosophers in German lands. With a generally small medical institutional network and a complete lack of lunatic asylums, such wars were obviously non-existent or far less apparent in Hungary before 1850. The professional status of the first viable lunatic asylum and its director physician was successfully bolstered in different ways. The private asylum’s professed aim carefully designed basic regulations and admission procedures stressed the institute’s medical qualities. Schwartzer’s complex theory of mental illness elaborated in the first comprehensive work on mental pathology published in Hungarian suggests an expert knowledge informed by different medical, neurological and psychological traditions prevalent in Austria and Hungary. These included a form of humoral pathology embraced at the time in both

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Viennese and Pest medical circles, elements of Enlightenment dynamicvitalism and neurology, and of Romantic psychiatry. With an idiosyncratic combination of these traditions, Schwartzer managed to conciliate the oppositions between organicist and psychicist approaches as well as to claim special expertise within the medical community for the alienist trained in mental pathology. Schwartzer’s eclectic theory represents a remarkably holistic view of the human being complemented with a refined psychology, where physical organs and processes, the workings of the nervous system, mental functions, sensations and moods/feelings were closely connected. Such a psychologically underpinned expertise and attitude certainly surpassed those of the general physician. While the physical disorders responsible for mental dysfunction necessitated general doctoring, the knowledge of the alienist/psychiatrist far exceeded that of the general doctor. In terms of treatment, it was the “psychic” cure embraced in the notion of moral therapy that provided legitimacy for the therapeutic asylum and bolstered psychiatric expertise. Schwartzer placed an emphasis on individual treatment, introduced the no-restraint system and the kind treatment of patients with the elimination of brutal coercion, although the strait-jacket and tying raging patients to their beds remained a practice, at least in the first period of the asylum’s history. Schwartzer’s role and influence was outstanding in the history of Hungarian psychiatry. His book remained the only comprehensive textbook for three decades and he trained the next generation of psychiatrists in the country. Károly Bolyó, Gyula Niedermann, Károly Laufenauer, Jen˝ o Konrád, Károly Lechner and his son Ottó Babarczi Schwartzer later became significant members of the profession and held high positions in medical and psychiatric circles. They gained their primary professional experience at the Schwartzer private asylum, became the first medical staff and directors of Lipótmez˝ o National Lunatic Asylum, the first lecturers at the Medical Faculty and directors of later established asylums and psychiatric hospital wards. With his students as intermediaries, many of Schwartzer’s ideas and the practices characterising his private asylum were transported to public asylums established in the 1860s and beyond. That some of Schwartzer’s ideals, for instance, individualised care could not be adequately implemented is due to the speedily deteriorating conditions within these new institutions.

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Hungarian psychiatry went through a period of growth during the second part of the nineteenth century. In the flourishing times after the political compromise with Austria in 1867, many psychiatric institutions were established in the country. This institutional growth, however, was not matched with a quality of care and treatment dreamed by state officials and psychiatric professionals. Although the second in the country, the Lipótmez˝ o public lunatic asylum became the foremost mental institution for decades. It gave rise to powerful metaphors and became an abstract concept in the public mind. In the eyes of the subsequent generations of psychiatrists, the establishment of Lipótmez˝ o became a symbol of national independence and civilised statehood as well as a pledge for development in mental health care. The directors and subsequent doctors of the asylum travelled to many European countries to visit foreign mental institutions and take their experience back. In the period between 1868 and 1908, three out of the four directors received their diploma at the Medical Faculty in Budapest and had their first encounters with mental patients at Schwartzer’s private asylum. Elements of the Schwartzerian heritage are well observable in the history of the institution. Gyula Niedermann embodied the Schwartzerian charismatic alienist with boundless psychic power over his patients who relied on moral treatment and psychic influence rather than physical restraint. A general rejection of resorting to physical coercion was shared by the directors and doctors who shaped asylum life. The restraint tools Lipótmez˝ o was originally equipped with were discarded at the opening of the asylum. The strait-jacket was in practice exclusively used upon the order of the doctor until Niedermann terminated their use in 1884. To what extent it was a rhetorical distancing from any form of restraint is hard to tell. By the turn of the century, there is evidence that psychiatrists had a more nuanced understanding and elaborate discourse on this issue. The use of strait-jacket was seen as acceptable in professionally justified cases and issues such as to what extent medication was a form of “chemical restraint” and whether it was possible at all to treat patients in mental institutions without any form of restraint were more openly discussed. Asylum case histories also testify that the asylum management used less obvious disciplinary measures by, for instance, moving patients between the different “departments” of the asylum which apparently had a deterring effect. The use of the dark isolation cells continued until 1896, when they were transformed into normal rooms.

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The same year signifies the introduction of bed treatment and modern hydrotherapy by Károly Bolyó and Jakab Salgó which allowed a freer treatment of patients, including permission for patients from closed wards to inhabit the institute’s parks and later the asylum neighbourhood. Free treatment first initiated at Lipótmez˝ o was subsequently introduced to allpublic asylums. The Schwartzerian influence is also visible in the emphasis placed on the patients’ occupation, the use of work therapy and amusements. During his long directorship, Niedermann managed to modernise the institution by successfully fighting tuberculosis, improving the food and the quality of the nursing staff. The latter was especially important since, in their daily contact with inmates, nurses regularly committed a variety of abuses against those placed under their care. With the advent of public state asylums in the 1860s, the issue of the legal arrangement of institutional mental health care came to the fore. The organisation and financing of mental health care were closely interwoven with and developed parallel to those of general health care for poor patients in public institutions. In terms of financing care, legislation defined financial responsibility starting from below and moving upwards: from the family through the community, towns and counties, to the state. In the complex system of the division of responsibilities, a crucial aspect was the question of the mental patient’s dangerousness and curability. As a rule, the dangerous and curable patients had to be taken care of at mental asylums, while the care for incurable and not dangerous patients had to be organised by the communities (and not in institutions run by the state). Prior to 1898, in the case of curable or dangerous patients, the state was willing to finally cover patient costs from public funds in the case of poor countryside communities that did not have the resources to achieve this task. While municipal authorities attempted to avoid taking responsibility for either providing community care for patients not qualified forpublic asylum care or paying the asylum costs for poor patients without solvent relatives, the state regularly complained about the “unjustified” financial burden imposed on the Treasury. Crucial change in this respect occurred in 1898 when the state generally took over from the community the financial burden of poor patients’ hospital care. This included mental patients in mental asylums, hospitals and curable or dangerous mental patients in home care. In the Dualist period, different aspects of asylum life as well as the bureaucratic and legal conditions of patient management were also elaborately defined. However, considerable discrepancies existed between

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regulation and implementation. In spite of that the medical and bureaucratic requirements of admission, discharge and guardianship were clearly defined, the reality of these was chaotic. Many important pieces of medical and bureaucratic information were missing at the time of admission which was disadvantageous to the institute, treatment as well as the judgement of the individual cases. Furthermore, mental institutions admitted patients who were not supposed to be treated in these institutions at all (“idiots,” “cretins” and epileptics who were neither curable nor dangerous). Shortcomings in the medical and bureaucratic aspects of admission and management remained characteristic throughout the period. Local communities and different types of mental institutions sent patients to each other without following the regulations. In the 1880s and 1890s, overcrowded psychiatric hospital wards transferred their incurable and not dangerous patients to mental asylums rather than back to their domicile to be treated in community care. In the 1890s, large state asylums rid themselves of their incurables by filling up the newly built “annex” mental wards in countryside hospitals which were originally designed to provide care for local mental patients. Budapest public hospitals, with the function to provide care for the capital’s population with domicile there, often admitted poor mental patients coming directly from the countryside which further aggravated overcrowding in these institutions. In Budapest, where local funds were more abundant than in poor countryside regions, the practice showed that numerous incurable and non-dangerous mental patients qualified for community care ended up in Angyalföld public asylum or the psychiatric ward of the Buda Hospital of the Hospitaller Order. Many mental patients were escorted to institutions in shameful conditions, by the gendarmerie. By the end of the 1880s, this chaotic situation and the flow of patients paralysed treatment in many mental institutions. It was morally difficult for directors and doctors to refuse patients, while the admitted incurable and dangerous patients who were from time-to-time taken to the ward meant a great burden for the hospitals as well as the asylums. The 1876 Act established an “external control system” in private asylums and hospital mental wards, while in public asylums, it introduced the “observation-system.” With this double system, the 1876 Act laid far more power into the hands of thepublic asylum director who, with a lack of external control, could alone decide about the insanity of his patients. This concentrated and uncontrolled power of the director was harshly

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criticised by the psychiatric community which saw it as destructive to the profession’s reputation as well dangerous to individual freedom. Although the requirement and conditions of placing a mental patient under guardianship were mentioned in different documents, no laws or decrees systematically and satisfactorily regulated the question. In reality, neither the existing requirements concerning guardianship, nor the clear regulation for external control were properly implemented in the country. To this illegal and chaotic situation, the courts also contributed with their often-hesitant behaviour. The prevailing practice in these respects caused problems and raised criticism from the psychiatric profession. Finally, the practical difficulty of executing external control in all institutions in the countryside was due to the general lack of experts. There were simply no available psychiatrists who were not already employed in the certain mental institution. Psychiatrists saw the only solution in making psychiatry compulsory study at the Budapest Medical Faculty, thus securing adequate supply of experts in institutions. Mental health care was in a vicious circle. While the pressure on mental institutions due to the low number of beds for the mentally ill in the country made the execution of legal regulations problematic, these considerable discrepancies between legal requirements and the actual practice contributed to a worsening of treatment and life conditions in these institutions. The reconstruction of the patient population at three significant Hungarian asylums suggests unique features compared to other European countries. Hungarian asylums drew patients from all over the multi-ethnic and multi-denominational country which resulted in a patient population rich and complex in terms of ethnicity, religion, culture, language and socio-professional composition. The analysis of these aspects of the patient population allows the critical revision of a number of claims prevalent in psychiatric historiography or in late-nineteenth-century psychiatric literature. First, the over-representation of certain social groups can be explained not by deterministic biological interpretations (as was often done in the case of the Jews, for instance), but rather with the degree of that group’s “medicalisation,” that is, the willingness to trust and rely on medical services. The distribution of beds in mental asylums followed the logic of the socially unequal development of “medicalisation” of society in Dualist Hungary, rather than a logic of inequality in terms of morbidity proper.

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This interpretation, however, does not exclude the significance of sociopathological risks that could contribute to a higher incidence of mental disorder among certain social groups. The analysis also suggests the inadequacy of the claim—widely accepted in psychiatric historiography—that madness became a “female malady” in both cultural representation and institutional reality in the mysoginistic male world of the nineteenth century. While contemporary perceptions and treatment of female insanity indeed reflected broader cultural assumptions about the nature and social role of women, there was no female over-representation in these mental institutions, just the contrary. The female icon of, for instance, the hysteric woman was undoubtedly pervasive in psychiatric writings and the cultural imagination of the period (and supplied a portion of the clientele of nerve clinics). It, however, was complemented with the figure of the demented male paralytic patient which equally marked the writings and did in fact dominate asylum reality (with their about 30% representation among men in such institutions). Evidence gained from the study also suggests that the enormous influence attributed to female reproductive functions and biological processes on the mental state in nineteenth-century psychiatric texts was a myth. Female reproductive biology did not affect mental disorders in a way that became manifest in asylum admission statistics. If biology worked, it worked via the social differences between women and men’s sexual practices. Gender mattered not for women but for men, due to syphilis. Similarly to European trends which testify a return to the era of the custodial function after the great hopes of earlier asylum reformers evaporated by the end of the nineteenth century, large Hungarian asylums were overcrowded by patients by the 1880s. While most alienists urged further asylums to be built in the coming decades, the state chose a highly criticised but much cheaper solution of forming “annex” mental wards. A number of such mental wards were set up at hospitals in the country in the 1880s and 1890s, which mostly served to take over incurable patients from large state mental asylums. These mental wards generally lacked professional nurses and psychiatrists, and there was no adequate control of the patients’ admission and living conditions. They almost immediately got overcrowded as well. By 1900, this situation urged psychiatrists to look for alternatives in other types of institutions and psychiatric practices. Many argued for the establishment of small institutions specialised in different areas on the

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model of tuberculotic clinics: institutes for epileptics, “imbeciles,” “idiot children,” alcoholics, nervous patients and criminals. Revealingly, such institutes emerged almost entirely in the private sector, with the exception of the state-founded National Observation and Mental Hospital for Persons in Detention and Prisoners established by the Ministry of Justice in 1894. These small institutes were partly designed to relieve large mental institutions of their most burdensome patients (except for the “nervous patients” who were not seen as the most problematic inmates) and provide special groups of the mentally ill with more tailor-made treatment, performing these functions also in a more cost-effective way. Some of these initiatives did not lead to considerable institutionalisation, such as in the case of epileptics or “idiots”, although some achievements were reached in the educational sphere for these groups. Other initiatives seem to have been rather successful and had a considerable impact on the mental health care in the country. These included the emerging new world of sanatoria serving the middle and upper-class nervous patient clientele (while calls for the establishment of “people’s nerve clinics” for the poor remained without any realisation). The most successful alternatives that emerged on the turn of the century were family care and colonial settlements (or rather, a combination of the two), even if in compromised forms. Patients placed to live with foster families meant a freer life for them and a relatively easy way of earning a living for the families. The colony, ideally a spacious mental institution set up on a large territory in the countryside, constituted of a centre and many small houses rather than huge closed buildings where patients lived more freely. It was mostly a self-sustaining economic unit organised around some agricultural or other occupation which also provided the possibility of work therapy. With a keen eye on Western European solutions, Hungarian experts widely discussed possible forms of family and colonial health care provision. Yet in the end practical factors— mostly the lack of adequate financial resources—determined what kind of arrangements were implemented. Several colonies were set up around existing institutions (large asylums and later small hospital mental wards which functioned as the centre) where patients were given out to foster families scattered in neighbouring villages. All parties seemed to benefit from this solution: at least as it transpires from professional accounts: patients could lead a more dignified, calm and free life, while the colony economically boosted the local region by providing a living to many families, also elevating hygienic standards of life of those involved due to the

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regular visits from the centres to check the patients and their circumstances. Finally, it was also an economical solution for the state, as the patient care costs were cheaper in colonies and family care than in closed mental institutions. Aside from the institutional provision of care, significant changes occurred in the last third of the nineteenth century that were crucial for psychiatric professionalisation as well as the production of psychiatric knowledge. The first signs of the failure of the therapeutic asylum, the influence of modern medical laboratory and experimental research that strengthened in the Viennese and Budapest Medical Faculties following the university reforms in the middle of the century, and the strong influence of German organic psychiatry led to the rise of neuro-scientific research in Hungarian psychiatry from the 1870s and the establishment of the university clinic in the early years of the 1880s. The Budapest Department of Mental Health and Pathology and its related clinic provided the conditions for the growth of academic psychiatry and the beginning of original research in Hungary. The appearance of these institutions represents the institutional and intellectual expansion of psychiatry within the medical sciences as well as fragmentation of psychiatric practices and theories within the profession. Laufenauer’s department and the attached mental and nerve-clinic became the centre of modern neuro-anatomical and histological research, clinical and laboratory experiments which significantly contributed to the generation of original research in the country. By this time, the strengthening psychiatric profession proved open to new influences and there was no considerable delay in reflecting on the latest German, French, British and Swiss ideas. Biographies of leading Hungarian psychiatrists suggest that more of them visited outstanding centres of research throughout Europe and cultivated good personal and professional relationship with foreign psychiatrists. Interestingly, the fierce opposition from the ranks of traditional asylum doctors against the establishment of the psychiatric clinic and the introduction of scientific research that characterised German, Austrian and French psychiatries in the second part of the nineteenth century is hardly visible in Hungary yet in the 1880s. The explanation, in my view, lies in the socio-professional circumstances of Hungarian psychiatry. Hungarian history of institutionalised psychiatry is shorter and, in a sense, more condensed than that of other national psychiatries in the West. Due to the relatively late appearance and low degree of institutionalisation,

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the asylum psychiatry tradition was not as long and deeply rooted as in other countries. The older representatives of asylum psychiatry, such as Schwartzer, Gyula Niedermann and Károly Bolyó, did not express adversity to academic psychiatry. By the 1880s, Schwartzer was hardly active and relied on his son under whose work laboratory investigations were introduced into the daily activities of doctors at the private asylum. Niedermann was the first to publish on Western results in neuro-pathology related to paralysis. Bolyó virtually ended publishing in Hungarian medical journals from the 1870s. Furthermore, the possibilities for training and acquiring practical experience were more uniform for the next generation of psychiatrists and thus this small psychiatric elite was rather like-minded. For Laufenauer, Lechner and Konrád, early training was confined to the Hungarian capital, and they first encountered mental patients in the Schwartzer asylum. Subsequent visits to foreign institutions made them more open to new approaches while their early asylum experience remained crucial. All this resulted in a more closely connected professional elite and perhaps a less hostile environment in the first phase of psychiatric professionalisation between the 1860s and 1880s. What should be added to this is that under Laufenauer’s leadership, the psychiatric clinic became a place for the central distribution of patients in the network of mental institutions in which the latter had their own place and role. As the leading figure in academic psychiatry, Laufenauer did not call into doubt the legitimacy of asylum psychiatry. Rather than sharpening the opposition, his work was instrumental in integrating the institutionally and intellectually fragmented profession from the 1880s through the end of the century. Concerning the question of the professional elite, in spite of early differences, these did not become manifest in critical opposition within the elite until younger doctors or colleagues with different background began to express their dissenting views in the expanding professional forums for publications at the end of the 1880s. Jakab Salgó is an excellent example. Although the same age as Laufenauer, after receiving his diploma in Vienna he worked for years in the Austrian capital. He returned to Budapest as an “outsider” and became a ward doctor at Lipótmez˝ o in 1884. In 1890, Salgó published his mental pathology textbook that contained his attack on modern psychiatric laboratory research and became the staunchest advocate of asylum psychiatry. The analysis of hypnosis and hysteria research in the 1880s–1890s suggested deepening intellectual and institutional divisions within the

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profession. On the one hand, it illustrated the nature of experimental research related to the university clinic and the assumed usefulness of such research in a deeper understanding of the function of the brain and the nervous system. Such experimental research was also used to bolster the scientific status and credentials of a maturing profession. On the other hand, it suggested crucial differences in views of mental and nervous disorders and in attitudes towards therapy and research. Academic researchers and neurologists’ occupation with experiments as well as the therapeutic use of hypnosis in their outpatient nervous practice sharply opposed the interest of asylum doctors in more traditional therapies of mental disorders. Disillusionment with the usefulness of neurological sciences for therapeutic purposes in the 1890s sharpened the rivalry between the asylum and the small university clinic. By this time, the former represented overcrowdedness and the overuse of sedatives, the latter was criticised for an inadequate approach to mental patients, and both could show little therapeutic success. This lack of understanding crystallised in turn-of-thecentury debates over the question what kind of psychiatric knowledge and experience students should acquire during their university studies. The argument for the primary importance of clinical practice within the asylum where the numerous physical and psychic manifestations of the entire course of mental disorders could be observed in a great number of patients (as well as where the administrative and forensic aspects of the psychiatrist’s work could be learnt) reflects asylum psychiatry’s attempt to shift the attention to the brain and nerves back to the living patient and the manifestations of his illness. This argument was juxtaposed with the significance of neuro-scientific research characterising university psychiatry. Laufenauer’s solution for this “split mentality” of turn of the century Hungarian psychiatry was integration of different psychiatric approaches that became manifest in the new clinic he lobbied for many years and which finally opened years after his death in 1908. The University Clinic of Mental and Neuro-pathology built in the modern pavilion system close to the other university clinics on Balassa Street became an efficient centre of psychiatric training. Considerably larger than the old clinic, it made the long-term observation and treatment of a large number of mental and nervous patients possible while it was also equipped with modern laboratories for neurological research. The clinical trend and reformed patient observation supported by its head, Ern˝ o Moravcsik, “rehabilitated” the

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patient by pursuing a more holistic view. At the clinic, Moravcsik used methods of experimental psychology (also supported by Laufenauer at the old clinic at the end of his life) and supported the first representatives of psychoanalysis at a time when other psychiatric circles detested the movement. The new university clinic thus proved open to diverse organic and psychological approaches, served an integrative function in a period of fragmenting psychiatric practice and temporarily put an end to the rivalry between the traditional asylum and the former university clinic. The various institutional settings, from which I singled out the asylum and the university clinic, together with their distinct practices and views of the psychiatrist’s role, helped frame different models of the doctor, the patient and their relationship. In the early private mental asylum where moral therapy was professed in the 1850s and 1860s, the asylum community was framed as a family which mirrored the familial hierarchy cherished in society. The doctor was a patriarchal figure while the patient was seen as a child into whose life the doctor (re)introduced order and discipline. Mental illness was understood as a childlike state, and treatment consisted of a mastery of control over the deluded childish psyche and a manipulation of fear. The doctor–patient relationship was characterised by a very uneven power-relationship, the patient’s great exposure to the doctor. The fragmentation in institutions and views on mental illness, as well as the new emphasis put on alternative functions of the profession (like academic research), brought about a multiplication of the frames within which new models of the doctor and the patient emerged by the end of the century. From these, I discussed the stereotypical figures of the new type of researcher conducting histological and anatomical studies, and the hypnotist interested in physiological and other experiments. The first, with his preoccupied focus on brain sections and histological research, reduced the patient to the brain, the nerves and the nervous system, with little sign of interest in the living patient, not to mention the holistic view professed by asylum doctors. Hypnotic research shows a fragmentation of the patient’s person and body. The physiological experiments with hypnosis demonstrate the primacy of experimentation over treatment where the unity of the mind, soul and body of the person was sacrificed. Greatly exploited, the patient was reduced to physiological functions and appeared in these experiments as a “dissected frog” whose reflex functions were minutely studied. Such research raised moral questions concerning experimentation which often revealed the unappeasable curiosity of doctors as well as suggested the

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blurring of the boundaries between research and therapy in which the latter was often used as a pretext for the former. While these experiments still demonstrate the enhanced power of the doctor over the patient, doctors in such experimental settings were more exposed to the patients than in the asylum setting, since experimental success greatly depended on the patients’ contribution. The experiments from the 1880s demonstrate the mutual relationship between medicine and social thinking. The medical framing and imagining of hysteria and hypnosis were informed by prevalent social values while at the same time psychiatry’s normative function in the medicalisation of deviant behaviour reinforced socially sanctioned boundaries that distinguished normal from abnormal, acceptable from deviant and healthy from pathological. A growing literature produced by psychiatrists with very different background illustrates a significant shift and expansion in psychiatrists’ understanding of the profession’s role and function by the turn of the century. Due to degenerationist thinking and to the therapeutic nihilism surrounding the large number of alcoholics, paralytics and the poor destitute in large asylums and the numerous patients with nervous disorders seeking help at the nerve clinics, strong social criticism was voiced within the psychiatric profession by the close of the century. Unable to cure the results of social problems related to poverty, alcohol consumption, prostitution, unhealthy life habits, capitalist development and civilisational forces, the profession sought the solution in social reforms in these areas. The claimed professional expertise originally focused more on the individual person and the patient population within the psychiatric institution was in parallel extended to the larger social domain. Shell-shock or war neurosis during the First World War provided yet another area for psychiatrists to make their social and political involvement ever more visible, the psychiatric expertise nationally and economically useful in society. The social factors in the aetiology of mental disorders have always been accentuated by doctors of the mind. But now the health of society was at stake. The new element in turn of the century psychiatry is the claim for active intervention in solving social problems with the psychiatrist’s expertise. Prophylactics became increasingly important in numerous psychiatric works that laid emphasis on aspects of healthy living and contained a hygiene of mental health. Such an extension of psychiatric expertise to social areas and pervasion of everyday life certainly demonstrates that the psychiatric profession strengthened by the turn of the

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century. It elaborated its manifold roles and functions in society and was not unsuccessful in its attempt to gain cultural monopoly over a number of issues related to the hygiene of everyday life as well as a “healthy” society.

Bibliography

Archival Sources Archives of the Lipótmez˝ o National Mental and Nervous Institute, Budapest. Women Patients’ Files from the Years 1868–1915. Male Patients’ Files from the Years 1901–1902. (No catalogue numbers.)

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———. 2018. “Single Rooms, Seclusion and the Non-restraint Movement in Britain, 1838–1844.” Social History of Medicine 31, no. 4: 754–773. Torda, Ágnes. 1995. “Egy tudományos m˝ uhely létrejötte a századfordulón” (The Emergence of a Scientific Workshop at the Turn of the Century). In Pszichológia Magyrországon (Psychology in Hungary), edited by György Kiss, 31–56. Budapest: Országos Pedagógiai Könyvtár és Múzeum. Turda, Marius. 2014. Eugenics and Nation in Early 20th Century Hungary. London: Palgrave Macmillan. Varga, Lajos. 1960. Részletek a magyar közegészségügy történetéb˝ol (különös tekintettel az Országos Közegészségügyi Tanács megszervezése és els˝o negyedszázados m˝ uködésére) (Chapters from the History of Hungarian Public Health Care, with Special Attention to the Formation and 25-years Work of the National Public Health Council). Ph.D. thesis, Budapest. ———. 1962 “A közegészségügy rendezése és helyzete hazánkban a múlt század utolsó negyedében” (The Organisation and Conditions of Public Health Care in Hungary in the Last Quarter of the Last Century). Az Országos Orvostörténeti Könyvtár Közleményei (Publications of the National Library for the History of Medicine) Supplement 1: 3–144. ———. 1964. “Az Országos Közegészségi Tanács kiemelked˝ o orvos tagjai (1868–1893)” (Eminent Doctors in the National Public Health Council, 1686–1893). Az Országos Orvostörténeti Könyvtár Közleményei (Publications of the National Library for the History of Medicine) Supplement 2: 5–279. Vörös, Károly, ed. 1978. Budapest története (The History of Budapest). Vol. IV. Budapest: Akadémia Kiadó. ———. 1987. “A m˝ uvel˝ odés keretei és intézményei” (The Frames and Institutions of Education). In Magyarország története (History of Hungary), Vol. 6/2, edited by Endre Kovács and László Katus, 1395–1477. Budapest: Akadémiai Kiadó. Weiner, Dora B. 1994. “‘Le Geste de Pinel’: The History of a Psychiatric Myth.” In Discovering the History of Psychiatry, edited by Mark Micale and Roy Porter, 232–248. Oxford: Oxford University Press. Zétény, Gy˝ oz˝ o. 1948. A magyar szabadságharc honvédorvosai (Military Doctors in the Hungarian War of Independence). Budapest: Egyetemi Nyomda. Zimmermann, Susan. 1997. Prächtige Armut: Fürsorge, Kinderschutz und Sozialreform in Budapest. Das “sozialpolitische Laboratorium” der Doppelmonarchie im Vergleich zu Wien 1873–1914. Sigmaringen: Thorbecke. Zsakó, István, ed. 1933. A budapesti angyalföldi Elme- és Ideggyógyintézet emlékkönyve, 1883–1933 (‘Memorial Book’ of the Budapest-Angyalföld Mental and Nervous Institute, 1833–1933). Budapest: Attila-Nyomda Részvénytársaság. ———. 1956. “Az egykori Országos Tébolyda keletkezésének története” (The History of the Establishment of the National Lunatic Asylum). Az Országos

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Index

A Academic psychiatry university psychiatry, 12, 198, 199, 381 See Scientific psychiatry Academy of Sciences/Hungarian Academy of Sciences, 54, 197, 202 Adél Bródy Israelite Children’s Hospital, 220 Admission bureaucratic criteria of, 167 legal regulation of, 178 Aetiology, 29, 116, 216, 313, 346, 352, 383 of mental illness, 116, 125 Age of Reason, 26 Ainay-le-Chateau, 260 Alcoholism alcoholics’ asylum, 270 alcohol problem, 270, 337–339 Alexander, Franz, 356 Alienist, 8

Allgemeine Krankenhaus, Vienna, 27 Alt, Konrad, 260 Alt school of family care, 260 Ambulantorium, 216 Amentia, 316 America/American, 102, 220, 258, 264, 271, 275 American Psychiatric Association, 314 Anarchism, 14, 329, 332 Anatomy, 20, 51, 68, 115, 195, 198, 199, 214, 217, 219 neuro-, 199, 213–215, 246, 322, 379 Angyalföld Mental Asylum, 58, 159, 164, 166, 170 National Institute for Nervous and Mental Diseases, 58 State Mental Institute, 257, 335 Anna O. “chimney-sweeping”, 355 “talking cure”, 355

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 E. Lafferton, Hungarian Psychiatry, Society and Politics in the Long Nineteenth Century, Mental Health in Historical Perspective, https://doi.org/10.1007/978-3-030-85706-6

423

424

INDEX

Annex asylums, 65, 251. See also Hospital mental wards Apáthy, István, 220 Ashkenazi Jews, 220, 295 Association for Natural Sciences/Természettudományi Társulat, 53, 214, 222 Asylum admission of patients, 62, 167, 172 alternatives to the asylum, 249, 256, 277 annex, 62, 65, 251 architecture, 21, 149 director of, 152, 159, 172, 173, 212 discharge of patients, 11, 106, 147, 171, 176, 178, 296, 297, 319 escape from, 168 life, 8, 10, 26, 29, 160, 166, 225, 293, 373, 374 overcrowding. See Pressure of numbers patient population, 13, 160, 187, 249, 259, 291, 293, 295, 298, 376 private, 10, 15, 26, 29, 47, 62, 63, 96, 101, 102, 104, 107, 135, 136, 152, 158, 159, 161, 164, 166, 171, 172, 178, 194, 247, 371–373, 375, 380 psychiatry, 9, 10, 12, 225, 245–247, 380, 381 public, 9, 10, 31, 41, 58, 61, 62, 76, 104, 132, 136, 146, 147, 149, 161, 162, 167, 168, 171, 172, 177, 178, 199, 212, 224, 234, 254, 276, 292, 294, 295, 327, 370, 372, 374, 375 reform of, 9, 369 state, 11, 58, 64, 66, 125, 159, 162, 166, 172, 206, 233, 257, 268, 274, 323, 374, 375

statistics, 7, 13, 313, 315, 317, 321 therapeutic, 9, 10, 23, 28, 30, 32, 47, 101, 126, 127, 131, 135, 206, 292, 369, 372, 379 See also Lipótmez˝ o, Nagyszeben, Nagykálló, Angyalföld Atavism, 341, 367 Austria, 2, 10, 15, 27, 28, 31–33, 59, 69, 71, 79, 114, 136, 149, 199, 200, 245, 246, 251, 256, 282, 292, 358, 371, 373 Austro-Hungarian army, 108 medicine, 113 Monarchy, 1, 3, 4, 309 B Babarczi Schwartzer, Ottó, 58, 63, 96, 103, 106, 108, 125, 129, 134, 135, 137, 144, 155, 171, 173, 177, 182, 189–191, 202, 243, 272, 277, 278, 308, 372 Bach, Alexandre, 152 Baden-Baden, 34 Baja public hospital, 263 Balassa, László, 219 Bálint, Alice, 356 Bálint, Michael, 356 Bálint, Rezs˝ o, 219 Baron von Türkheim, Ludwig, 116 Barrack Hospital , 352 Bath steam, 151 See also Hydrotherapy Dr. Batizfaly’s Sanatorium and Hydropathic Institute, Budapest, 271 Battie, William, 28, 77 Bed asylum, 32, 47, 58, 64, 153, 293, 294, 306, 376 hospital, 44, 58, 59

INDEX

number of, 41, 44, 60, 64, 206, 293, 376 treatment, 159, 161–163, 374 Bedside hospital medicine, 112, 113 Bedside medicine, 113, 197. See also Boerhaavian bedside medicine Belgium/Belgian, 103, 152, 255, 256, 258, 260, 275, 283 Benedek, László, 335, 360 Bene, Ferenc, 255 Berlin, 34, 68, 112, 198–200, 213, 216, 220, 258, 275, 362, 365 Bernheim, Hippolyte, 219 Bethlem/St Mary of Bethlehem/Bedlam, 21, 23, 26, 30 Bicêtre (Paris hospice), 27, 29 Biological psychiatry, 33, 34, 68, 198 Blum, Ödön, 160, 224, 254 Blum, Rezs˝ o Institute for Oligophrenic Children, Pels˝ oc, Hungary, 66 Board of Forensic Medicine/Igazságügyi Orvosi Tanács, 252 Boerhaave, Herman, 48, 111–113 Boerhaavian bedside medicine, 67 See also Bedside medicine Bolyó, Károly, 57, 58, 125, 130, 131, 133, 135, 140, 144–146, 152, 153, 158, 159, 164, 182, 185, 187, 202, 233, 247, 255, 372, 374, 380 Bonifazio hospital, 28 Bourgeois radicalism, 4 values, 29, 321, 334 Brain anatomy, 12, 30, 34, 196, 214, 248 dissection, 12, 193, 220 histology, 201, 213, 218, 220, 228, 229

425

pathology, 219 Breed/breeding, 341, 342 Breuer, Josef, 352, 353, 355 Bridge of Weir, Scotland colony near, 269 Britain/British, 33, 69, 355, 379 Broca, Pierre Paul, 118 Brown, John, 111 Brunonian/Brunonianism, 112, 113, 115 Budapest University Department and Clinic of Psychoanalysis, 356 Department of Forensic Mental Pathology, 68 Department of Internal Medicine, 214 Department of Mental Health and Pathology, 68, 194, 196, 202, 203, 245, 379 Department of Neurology, 68 Law Faculty of, 202 Medical Faculty of, 49, 62 2nd Internal Clinic, 347 See also University psychiatry Buda Private Lunatic Asylum. See Schwartzer Asylum Bugát, Pál, 55, 104 Burghölzli, 219 C Calvinist, 295, 307 Capitalism, 14, 23, 35, 329, 330 Care for the insane colonial, 258, 277, 278, 378 community, 60, 168–170, 254, 374, 375 family, 13, 24, 66, 159, 253–263, 267, 277, 378, 379 home, 63, 254–256, 374 hospital, 36, 37, 39, 41, 43, 44, 60, 63, 370, 374

426

INDEX

individualised, 136, 372 municipal, 95, 374 religious, 36 Catholic Church, 294, 295 Greek, 295, 305–307, 311 Roman, 151, 294, 295, 305, 307 Cell, 24, 27, 35, 45, 160–162, 208, 220, 253 isolation, 145, 150, 159–161, 373 Certificate of insanity, 167, 174 Chalfont St Peter epileptic colony, England, 269 Charcot, Jean-Martin, 68, 73, 219, 223, 347, 353, 362, 365 Charcotian, 353 Charisma, 132 doctor’s, 132 Charitable Society for Recovered Mental Patients, 158 Charity, 32, 158, 168, 265, 269, 270 Chemical restraint, 162, 163, 373 Chiarugi, Vincenzio, 28 Chicago Institute of Psychoanalysis , 356 Church, 9, 19, 20, 25, 27, 35, 41, 42, 44, 45, 48, 135, 339, 370, 371 Chyzer, Kornél, 93–97, 153, 179, 182–184, 187–190, 241, 256, 257, 259, 260, 266, 276, 277, 281, 282, 284, 286, 288 Clinic mental, 203, 211 nerve, 216, 217, 219, 303, 377, 383 psychiatric, 9, 11, 12, 68, 193, 194, 196, 200, 204, 212–214, 221, 223, 225, 245–247, 379, 380 university, 20, 66–68, 196, 199, 203, 206, 211, 213, 215, 216,

226–228, 248, 316, 379, 381, 382 Clinical medicine, 33, 54, 67, 194, 198 Cocaine/cocainism, 108 Coercion in asylums bed treatment, 162 physical, 27, 28, 132, 133, 373 restraint, 11, 147, 151, 160 tools of, 164 use of, 11, 27, 147, 160 See also Strait-jacket Colony/Colonies, 13, 66, 255–257, 259, 260, 261–263, 267, 269, 378. See also Heterofamiliar system; Homofamiliar system Columbia Psychoanalytical Institute, 356 Community care, 60, 169, 170, 254, 374, 375 Confinement, 24–27, 38, 271, 304 Conolly, John, 31, 78 Cooter, Roger, 31, 78 Cosmopolitanism, 329 Council of GovernorGeneral/Helytartótanács, 36, 37, 42–44, 46, 48 Count Albert Apponyi’s Polyclinic, 219 Cranioscopy/Craniometry, 30 Crime, 2, 14, 131, 251, 274, 277, 329, 331, 337–339, 357 Criminal, 11, 13, 26, 66, 119, 157, 193, 207, 263, 264, 268, 274–278, 338–340, 378 Croatia-Slavonia/Croatia/Croats, 294, 295, 304 Csáth, Géza, 228 Csiky, József, 349, 364, 366 Cullen, William, 111, 112 Curable patients, 58, 63, 166, 258, 374. See also Incurable patients

INDEX

Cure, 34, 58, 66, 105, 126, 127, 194, 206, 225, 228, 274, 319, 320, 348, 349, 351, 356, 370, 372, 383 Custody custodialism, 9, 369 provision of custodial care, 9 Czech, 103, 149, 162 D Dalldorf system, 260 Dánfi, Mózes, 40 Dangerous, 26, 35, 37, 54, 63, 121, 124, 130, 160, 166, 169, 170, 178, 254, 258, 277, 335, 374, 375 mental patients, 35, 58, 63, 170, 250, 294, 330, 374 Darwinian/Darwinism, 331, 340–342 Decadence, 1, 3 Decadent movement, 14, 329 Décsi, Károly, 270, 280 Degeneration degenerate, 264, 269, 274, 339, 340, 342, 354, 355 degenerationist theory, 35, 354 Delirium tremens, 315, 337 Delusion, 40, 124, 126, 130, 134, 155 Dementia, 119, 165, 263, 315, 316 Denmark, 258 Denomination, 305, 307 Detention house, 275 See Irrenstation Diagnosis, 14, 105, 198, 199, 216, 314, 345, 349 Diagnostic and Statistical Manual of Mental Disorders (DSM), 314 Dics˝ oszentmárton, 13, 260–262 colony, 13, 66, 260, 262 Dietl, Joseph, 80, 199

427

Discipline, 6, 10, 12, 19, 20, 29, 33, 40, 55, 57, 128, 126, 132, 135, 148, 163, 196, 249, 267, 275, 276, 382 Disposition (constitutional), 116, 117 Döbling asylum, 31 Doctors doctor and patient, 131 doctoral supply, 44 Donáth, Gyula, 53, 241, 269, 282, 287, 338, 358, 359, 361, 362 Dumb/Dumbness, 102, 172, 264, 349 Durkheim, 304 Dutch, 33, 258

E Ebbinghaus, Hermann, 215 Edinger, Edward F., 218, 219 Eger Bishop of, 39, 48 Hospital of the Hospitaller Order, 36, 39, 41, 48, 250, 294, 370 Lyceum, 48 Scola Medicinalis , 39, 48 Eisenach Treaty, 43 Electric treatment, 347, 351 Electroshock, 350 therapy, 350 Elias, Norbert, 29 Elisabeth Hospital of the Red Cross , 103 Poorhouse Hospital, 219 Engel, Joseph, 198 England/English, 5, 9, 26, 28, 29, 31, 32, 46, 64, 65, 103, 133, 152, 159, 213, 258, 264, 269, 275, 293, 337, 369, 371 Engstrom, Eric, 5, 80, 200, 213, 231, 233, 236, 278 Enlightenment Absolutism, 51

428

INDEX

Eötvös Loránd University, 48 Epilepsy/Epileptic institute, 13, 66, 263, 265, 267, 378 Institute for Oligophrenic Children, Pels˝ oc, Hungary, 66 psychosis epileptica, 316 ward, 270 See also Wosinszki, István, Epileptic Colony in Balf Epstein, László, 20, 22, 46, 69, 70, 72, 80, 86, 87, 96, 98, 138, 161–165, 179, 180, 182, 185–187, 190, 219, 230, 234, 238, 242, 256, 262, 273, 279–289, 335–338, 340, 341, 358–360, 362, 363 Erd˝ ody, Gábor Bishop of Eger, 39 Erlenmeyer, Adolph Albrecht, 317 Er˝ os, Ferenc, 7, 16, 364, 368 Escape, 69, 147, 154, 155, 160, 162, 168, 207, 252, 261, 274, 353 Esquirol, Jean-Etienne-Dominique, 29, 77, 116, 117, 142, 195, 317 Esterházy, Count Károly (Bishop of Eger), 48 Ethnic background, 295 ethnicity and mental disorders, 295 groups, 2, 56, 294, 312 Eugenics/Eugenic, 3, 14, 340–343. See also Race hygiene Excitement excitation theory, 120, 121 over-, 111 Expert/Expertise opinion, 62, 166, 177, 194, 342 psychiatric expertise, 13, 15, 41, 330, 357, 372, 383 Experiment experimental psychological, 242, 344

experimental psychology, 217, 226, 227, 333, 382 experimentation, 12, 33, 68, 206, 225, 355, 382

F Fabinyi, Rudolf, 180, 261, 282 Falret, Jean-Pierre, 116, 327 Family, 9, 10, 23, 38, 60, 63, 66, 101, 102, 126, 167, 201, 252, 255–263, 267, 278, 303, 311, 321, 334, 343, 382 care, 13, 24, 66, 159, 254–263, 267, 277, 378, 379 Faradisation, 272 Feldhof provincial asylum near Graz, 161 Female emancipation, 334, 337 insanity, 297, 321, 377 madness, 303, 321 malady, 14, 291, 297, 321, 377 Feminism, 14, 329 feminist movement, 336 Ferenczi, Sándor, 1, 7, 15, 16, 219, 228, 243, 346, 352–357, 361, 367, 368. See also Psychoanalysis Fifth Congress of the International Psychoanalytical Association, Budapest, 1918, 352, 356 First World War, 1, 8, 273, 343 shell shock, 344–346 See also War neurosis Fischer, Ignácz, 267, 284, 287 Fischer, Jakab, 58, 174, 190, 212, 273, 359 Flögl, Karl, 200 Folie, 315 Folk medicine, 9, 35, 36, 80, 370 Foucault, Michel, 24–27 Foucauldian, 25

INDEX

France/French, 9, 25, 27, 32, 33, 47, 51, 69, 103, 197, 245, 256, 369, 371, 379 Francis Joseph I, 47 Frank, Johann Peter, 112, 113 Franz II, Emperor, 113 Freud, Sigmund, 1, 2, 7, 228, 352–356 Freudian, 352–355 Frey, Ern˝ o, 219 Frimm, Jakab, 265 Insitute for “Idiots”, Budapest, 256, 264–267, 278, 342, 371, 375, 378 Fundus confraternitatum, 45 G Gall, Joseph, 30, 31, 112, 113, 118, 142 Galvani, Luigi, 115 Galvanisation, 272 Gaupp, Robert, 353 Gebhart, Lajos, 203 Geel, 23, 255, 258 Gender, 14, 119, 151, 292, 295, 299, 301, 309, 319, 334 difference, 292, 301, 302, 334 General Charity Association/Általános Közjótékonysági Egyesület, 270 Generale Normativum in re Sanitatis/Basic Health Care Regulation, 36 Germany, 27, 32, 33, 65, 66, 68, 199, 213, 245, 259, 264, 275, 293 German psychiatry/German university psychiatry, 5, 34 Glósz, Kálmán, 175, 191 Dr. Glück’s Sanatorium and Hydropathic Institute, Városligeti Fasor, 271 Goergen, Bruno, 31

429

Goffman, Erving, 25, 73 Goldstein, Jan, 5, 75, 77 Gonda, Viktor, 346, 349, 367 Good Templars, 337, 338. See also Masonic lodge Gortvay, György, 35, 52 Graz clinic, 204 Hospital Observation Ward, 317 Greek Catholic, 295, 305–307, 311 Orthodox, 151, 295, 306, 307 Griesinger, Wilhelm, 34, 198 Grósz, Lipót, 84, 85, 148 Grünwald Sanatorium, Budapest, 272 Guardianship, 11, 147, 166, 171, 172, 174, 177, 178, 253, 273, 376 temporary, 172, 177 Gyáni, Gábor, 43, 94, 326 Gyimesi, Júlia, 7 Gyöngyös, 65, 251 Hospital Mental Ward, 65, 251, 321 Gypsy/Gypsies, 295 Gyula public hospital, 45, 174, 253

H Habsburg Empire, 32, 33, 43, 49 Monarchy, 15, 70 Hajdu, Lilly/Lili Hajdú, 228 Halbwachs, Maurice, 304 Haller, Albrecht von, 48, 111, 113 Hanák, Péter, 3, 4, 15, 72 Garden and the Workshop, The, 3 Hanwell, 31 public asylum, 31, 78 Harmat, Pál, 7, 16, 243 Hartmann, Philipp Carl, 115, 197 Health paternalism, 32

430

INDEX

Heinroth, Johann Christian August, 34, 79, 112, 116, 118, 199 Hermann, Imre, 356 Heterofamiliar system, 260 Hippocratic medicine, 114 Hirschler sisters, 265 History of psychiatry national, 21 See also Psychiatric histories H˝ ogyes, Endre, 49, 137, 218, 221, 232, 238, 239 Hollós, István, 64, 156, 296–298, 300, 302, 304, 306, 309–312, 316, 319, 320, 334, 335, 337, 356 Home care, 63, 254–256, 374 Homeopathy, 114, 141 Homofamiliar system, 255 Hôpital Général, Paris, 24, 25 Horánszky, Nándor, 136–138, 285, 308 Horváth, Imre, 165 Hospital annex asylums, 62 building, 39, 250 number of beds in, 60 supply, 44, 59 See also Mental wards Hospitaller Order Buda Hospital of the, 41, 170, 375 Eger Hospital of the, 36, 39, 48, 250, 294, 370 hospitals of the, 64, 82, 83, 97, 323 Hudovernig, Károly, 217, 279, 281, 282, 284, 285, 363, 364 Humoralism, 109, 110, 112, 113, 116 Humoral pathology, 10, 109, 114, 123, 135, 371 neo-, 120 Hungarian Anatomy Institute, 214

Hungarian Council of Forensic Medicine, 159 Hungarian Physicians and Naturalists Society/Magyar Orvosok és Természetvizsgálók Egyesülete, 53, 57 Hungarian Psychoanalytic Association, 356 Hungarian Society of Medical History, 6 Hungarian Society of Mental Doctors , 160 Hydropathy/Hydropathic, 271 Hydrotherapy, 114, 159, 161, 271, 350, 374 Hygiene/hygienic daily, 151, 159 of everyday life, 3, 13–15, 330, 384 public, 68 See also Social, hygiene Hypnosis, 12, 194, 218–226, 247, 345, 347, 353, 380, 382, 383 Hypnotics, 162, 163 Hysteria/Hysteric hysterical anxiety, 344 hysterical conversion, 354 psychosis hysterica, 316

I Ideler, Karl Wilhelm, 69, 79, 112 Idiot/Idiocy, 119, 166, 168, 211, 256, 263–267, 278, 339, 375, 378 Illenau asylum, Baden, 144 Imbecile/Imbecility, 13, 61, 62, 66, 105, 155, 166, 172, 263–265, 267, 276, 342, 371, 378 Imperial Royal Institution for the Treatment and Care of the Insane in Bründlfeld, Austria, 31, 149, 200

INDEX

Incurable patients, 170, 259, 377. See also Curable patients Inheritance, 342 Insane/Insanity, 9, 14, 15, 22–30, 34, 35, 37, 38, 41, 45, 61, 62, 64, 101, 104, 105, 107, 110, 111, 126, 127, 131, 135, 149, 156, 171, 172, 177, 200, 313, 329–331, 340, 375 Institute for “idiots” (hülyék), 265 Institute for the blind, 264 Institute of Brain Histology, Budapest, 228 Institution alternative, 64, 267 specialised, 270 Institutionalisation, 9, 293 10th International Anti-Alcoholism Congress, Budapest 1905, 337 International Psychoanalytic Association/Psychoanalytical Association, 356 Irrenstation, 275 Israelite, 151, 264 Italy/Italian, 9, 65, 293, 369 J Janet, Pierre, 353 Jendrássik, Ern˝ o, 41, 214, 223, 346, 347 Jendrássik, Jen˝ o, 68 Jesuit, 48, 51 Jew/Jewish Ashkenazi, 220, 295 doctor, 4, 307 nervousness, 14, 292 Joseph II, Emperor, 27, 41, 45, 50, 51, 54 K Kahlbaum, Karl Ludwig, 195

431

Kant, Immanuel, 20 Kaufmann, Fritz, 350 Kétly, Károly, 203, 232, 236 Klein, Melanie, 356 Koch, Julius Ludwig August, 340 Koller, Ferencz, 45 Kolozsvár (Cluj) Department and Clinic for Mental and Nervous Pathology, 250 Medical Faculty, 50 Könnyei, István, 220 Konrád, Jen˝ o, 58 Korányi, Frigyes, 67, 211, 214, 218, 317, 327, 359, 366 Korányi, Sándor, 218 Kovai, Melinda, 7, 17 Kövér, György, 61, 71, 85, 94, 95 Kraepelin, Emil, 98, 227 Krafft-Ebing, Richard von, 161, 204–206 L Laboratory experimentation, 68 medicine, 67 research, 12, 194, 197, 198, 225, 380 Lamarck, Jean-Baptiste Lamarckian, 341 Lamarckism, 340 Laufenauer, Károly, 58, 68, 69, 135, 143, 153, 161, 174, 176, 191, 194, 196, 200–208, 210–218, 221, 222, 226, 227, 229, 231–234, 236, 237, 239, 240, 247–249, 255, 257, 266, 274, 279, 281, 282, 286, 313, 326, 359, 365, 372, 379–382 Law legislation, 60, 63, 225, 374 See also Legal Lazareth Hospital, Vienna, 152

432

INDEX

Lechner, Károly, 135, 163, 187, 242, 243, 247, 250, 279, 331, 332, 338–340, 342, 343, 359, 362, 363, 372, 380 Legal, 10, 103, 174, 178, 339, 376 Legal regulation of admission, 11, 147, 166, 178, 375 of discharge, 11, 147, 166, 178, 375 Placement under guardianship, 11 versus practice, 165 Legislation for the insane, 60. See also 1876 Public Health Care Act Leiden University, 33 Leidersdorf, Maximilian, 159, 199 Lenhossék, József, 115, 214, 217, 220 Lenhossék, Mihály, 115, 142, 214, 217, 227 Leopold I., Emperor, 45 Lesky, Erna, 28, 52, 77–80, 88–91, 112, 115, 140–142, 180, 198, 231, 278 Lévy, Lajos, 356 Lewis epileptic colony, 269 Liberalism, 3, 4 Lipótmez˝ o, 8, 10, 21, 47, 58, 62, 103, 125, 136, 147, 149, 152–154, 157–159, 161, 162, 165–168, 172, 201, 202, 206, 208, 210, 212, 248, 250, 257, 276, 292, 294, 296–298, 301, 305, 311, 312, 314–320, 332, 334, 336, 337, 373, 374, 380 Royal National Lunatic Asylum, 8, 10, 58, 147, 152, 157, 166, 292 Lockean, 125 Lower Austrian Provincial State Commission, 246

Lunacy/Lunatic, 26, 46, 47, 58, 62, 64, 101, 103–105, 107, 134–136, 147, 151, 152, 154–156, 166–170, 292, 295, 369, 371–373 Lunbeck, Elizabeth, 330, 357 Lutheran, 112, 151, 295, 306, 307 Lyachovics, János, 69, 125, 130, 133, 134, 140, 144–146 M Mad madness, 14, 19, 22–24, 26, 35, 38, 121–124, 126, 133, 291, 297, 313, 314, 321, 346, 371, 377 See also Mental illness, Insanity Madhouse, 8, 23, 104 Magnan, Valentin, 159, 195, 219, 340 Malfatti, Johann von, 114 Mania, 111, 118, 119, 123, 132, 133, 314, 317 Marchi, Vittorio, 218 Mária Ludovica, Empress, 152 Maria Theresa, Empress, 37, 44, 48 Markhot, Ferenc, 40, 48 Markusovszky, Lajos, 55, 56, 203 Marriage, 303, 304, 342, 343 Masonic lodge Health Lodge, 337 See also Good Templars Materialism, 33, 197 Maudsley, Henry, 213 Mauer-Öhling Asylum, Austria, 32, 251 Medical Jacobinism, 52, 113 knowledge, 2, 6, 116, 118, 197 marketplace, 81 police, 32, 79 power, 2

INDEX

professionalisation, 2 Medical Faculty curriculum, 50, 194, 201 examination, 50 Kolozsvár (Cluj), 50 Nagyszombat, 44, 48, 51 Pest/Budapest, 49, 51, 103, 115, 134, 194, 196, 198, 201–203, 211, 212, 214, 219, 223, 226, 227, 247, 376 training, 37, 44, 48–50 Vienna/Viennese, 31, 32, 47, 51, 102, 112, 116, 159, 198 Medicalisation, 292 Medical teaching, 23, 33, 44, 47, 48, 52, 54, 67. See also Vienna/Viennese, First Vienna School, Second Vienna School Medication hypnotics, 163 See also Sedatives Medicine academic, 83 bedside, 67, 113, 197 hospital, 33, 113 Hungarian, 6, 23, 48 Pest/Budapest culture of, 214 Viennese culture of, 52 Meduna, László, 220 Melancholy, 110, 111, 118–120, 122–124,, 131, 313, 316 Mental illness/disease/disorder aetiology of, 116, 125, 292, 346, 383 forms of, 8, 12, 134, 313, 314 amentia, 316 anorrhexia, 40 cretinism, 61, 168, 375 delirium tremens, 337 delusion, 130, 134 dementia, 165, 263 dumbness, 349

433

epilepsy, 111, 269, 315, 338 folie, 315 hysteria, 119, 218, 228, 247, 272, 316, 345–348, 352, 354, 355, 380, 383 idiotism, 265 imbecility, 342 mania, 111, 118–120, 123, 132, 133, 314, 317 melancholy, 110, 111, 118–120, 122–124, 131, 313, 315 monomania, 315 morphinism, 108 paralysis progressiva, 215, 218, 261, 299, 302, 317, 319, 321, 331, 334–336, 342, 357 Obstructio mesenterii, 40 paranoia, 32, 156, 314, 318 Phrenesis , 40 partieller Wahnsinn, 315 Verwirrtheit, 315 Mental wards, 64, 65, 97, 102, 105, 152, 171, 172, 174, 206, 251, 252, 275, 377 Mesmer, Anton, 114 Mészáros, Judit, 7, 16 Meyer, Adolf, 317 Meynert, Theodor, 34, 68, 159, 199–201, 213, 215, 216, 218, 246 Mind theories of the, 110 Miskolc public hospital, 152 Miskolczy, Dezs˝ o, 220, 232, 236–238, 243 Möbius, Paul, 35 Modernism, 3 Modernity, 3, 5, 35, 345 Moral freedom, 128

434

INDEX

therapy, 29–31, 126, 135, 372, 382 treatment, 10, 29–31, 101, 136, 155, 166, 270, 373 Moravcsik, Ern˝ o, 20 Morbus sacer, 269 Morel, Augustin, 35 Morellian, 340 Morphine/Morphinism, 108 Munich, 213, 220 N Nádasdy, Ferencz, 46 Nagy, Dezs˝ o, 155 Nagydisznód Colony, 13, 66, 262 Nagykálló National Institute for Nervous and Mental Diseases, 58 State Mental Asylum, 250 Nagyszeben Royal National Lunatic Asylum, 58, 152, 166 State Mental Institute, 66, 249, 254, 260, 262 Nagyszombat University, 44, 48 Medical Faculty of, 44, 48 Narrenturm, 27, 30, 31 National Alienist Congress, 63, 65, 173, 177, 211, 248, 253, 256, 265–267, 269, 274, 331, 340, 342 National Anti-Alcohol Association, 339, 363 National Institute for Nervous and Mental Diseases, 58 Nationalism, 4, 37, 51, 329 National Observation- and Mental Hospital for Persons in Detention and Prisoners (NOMH)/Letartóztatottak és Elítéltek Országos Megfigyel˝o és Elmegyógyító Intézete, 267, 273, 274, 378

National Public Health Council/Országos Közegészségügyi Tanács , 57, 61, 62, 103, 167, 225 National Public Health Society/Országos Közegészségi Egyesület , 53, 57 Natural philosophy, 114–116, 197 selection, 340, 342 Németh, Ödön, 217 Nerve/Nervous exhaustion, 332, 345 system, 110, 111, 119, 120, 135, 201, 213–215, 217–220, 224, 248, 333, 335, 337, 347, 348, 355, 372, 381, 382 weakness of the, 333 Nervousness, 117, 120, 122, 272, 332, 333, 340, 357 Neurasthenia, 272, 330, 332, 333, 335, 336, 340, 342, 345 Neuro-anatomy, 213 Neurology/Neurologist, 10, 41, 135, 202, 214, 217–220, 228, 249, 346, 347, 350, 352, 353, 355, 372, 381 Neuro-pathology, 196, 201, 214, 216, 219, 226, 227, 380, 381 Neuro-scientific research, 11, 193, 215, 227, 248, 379, 381 Neurosis traumatic, 344, 345, 347–349, 351–354 war, 15, 333, 345, 346, 348, 352–355, 357, 383 Niedermann, Gyula, 57, 58, 135, 145, 152–159, 161, 182, 202, 215, 237, 247, 256, 282, 317, 327, 370, 372–374, 380 Niedermann’s Sanatorium, Rákospalota, Budapest, 66

INDEX

Nissl, Franz, 218 Nonne, Max, 353 Nordau, Max, 35, 358 No-restraint/Non-restraint, 31, 32, 132, 161, 162, 165, 246, 372 Nurse/Nursing, 11, 40, 107, 129, 133, 147, 153, 156–158, 160, 208–210, 249, 252, 253, 257, 261, 266, 275, 374, 377 O Obersteiner, Heinrich, 31 Observation macroscopic, 201 microscopic, 12, 193 patient, 33, 125, 197, 227, 381 ward, 158, 196, 200, 201, 203–205, 207, 208, 210–212, 216, 246 Observation system in asylums, 176. See also Legal regulation Observation ward at Saint Roch Hospital, Budapest, 205, 230 Observation Ward in Graz, 205 Oláh, Gusztáv, 21, 22, 72, 147, 152, 154, 156, 159, 160, 179–182, 185, 186, 250, 256–258, 273, 277, 279, 282, 283, 288, 289, 330, 335, 338, 339, 341–344, 358, 360, 362, 363 Opium/Opiate, 111, 131 Oppenheim, Hermann, 347 Order, 10, 11, 21, 24, 27, 29, 36, 39–41, 50, 61, 62, 110, 118, 121, 128, 131, 133, 135, 148, 151, 158, 161, 171, 174, 177, 201, 209, 216, 252, 314, 316, 343, 350, 373, 382 Organ, 52, 53, 111, 115 reproductive, 302 Organicism/Organicist, 31, 35, 330 Orthodox

435

Greek, 151, 295 Serbian, 311 P Pállfy, Count Károly József Jeromos, 46 Pándy, Kálmán, 65, 159, 217, 251, 258, 296, 298 Pápa Public Hospital, 39, 45, 352 Paralysis progressiva, 215, 218, 261, 299, 302, 317, 319, 321, 331, 334, 336 paralytic patients, 301, 302, 317, 318, 334 Paranoia, 32, 156, 314, 318 Parasitism, 332 Paris, 21, 29, 32, 113, 116, 159, 212–214, 219 Park Sanatorium, Dunaharaszti, 271 Parry-Jones, William, 26, 73, 76 Pasteur, Louis, 218 Pathology/Pathological anatomy, 12, 34, 198, 201, 215 cellular, 198 histology, 68, 198, 216, 218 humoral, 10, 109, 113, 114, 123, 135, 371 macroscopic, 198 mental, 8, 10, 14, 31, 45, 57, 65, 67, 68, 102, 104, 109, 118, 152, 167, 178, 194–196, 201, 202, 212, 215, 224, 226, 247, 248, 251, 314, 331–333, 371, 372, 380 microscopic, 198 neuro-, 196, 201, 214, 216, 219, 226, 227, 380, 381 Patient, 2, 7, 8, 13, 20, 33, 38, 43, 51, 59, 61, 62, 64, 65, 105, 106, 119, 125 as a child, 10, 135, 382 Patient population

436

INDEX

age distribution of, 300 distribution by mental illnesses, 206, 291 gender distribution of, 298 marital status of, 304 professional status, 14, 291 religious affiliation of, 14, 291, 304 social parameters of, 291 social status, 309 Pauperism, 14, 35, 122, 330, 331 Pázmány, Péter (Archbishop of Esztergom), 48 People’s nerve-sanatoria, 273 Perliczy, János, 48 Pest Society of Physicians - Royal Society of Pest Physicians, 8, 53 Pfisterer, Endre, 46 Phrenology, 30, 31, 112, 118 Physiology humoral, 109 hydrostatic, 111 mechanistic, 111, 352 nerve, 109 vitalistic, 123 Pietist, 112 Pinel, Philippe, 28, 29, 116, 225 Pisztora, Ferenc, 7, 98, 185, 243, 308, 309, 326, 364 Pléh, Csaba, 7, 16, 242 Pólya, József, 47, 62, 101, 104, 105, 157, 166, 194 Poor, 24, 26–28, 32, 36, 37, 39, 41, 43, 45, 51, 60–63, 133, 151, 168–170, 258, 269, 270, 277, 311, 370, 374, 375, 378, 383 Poorhouse, 43, 44, 206, 219 Porter, Roy, 26, 65 Posttraumatic stress disorder (PTSD), 345, 346 Poverty, 1, 2, 35, 43, 168, 249, 254, 339, 357, 383

Pozsony Hospital of the Hospitaller Order, 44 Pozsony Town Hospital, 44 Practice of admission, 96, 168 of discharge, 176, 205 of placement under guardianship, 166, 175 See also Law, legislation Prague, 27, 42, 134, 200 Precipitating factor, 116, 123, 124 Predisposition/Predisposed, 117, 274, 301, 339, 340, 342 Preservation of the species, 341 Pressure of numbers, 32, 64 Prison/Prisoner, 24, 35, 38, 172, 204, 254, 273–277, 338, 339 Private asylum bourgeoise family world of, 10, 11, 101, 135 Pólya’s Private Madhouse, 62, 104 Schwartzer’s Private Asylum/Buda Private Lunatic Asylum, 10, 47, 62, 64, 101, 102, 104, 105, 152, 166, 277, 371–373 See also Madhouse Prochaska, Georg, 114, 115 Profession medical, 3, 48, 52, 56, 178, 343 psychiatric, 5, 6, 12, 15, 41, 173, 174, 245, 346, 357, 373, 376, 379, 383 Professional expertise, 2, 329, 331, 383 Professionalisation, 2 Prophylactics/Prophylaxis, 3, 14, 270, 330, 331, 335, 337, 341, 343, 357, 383 Prostitute/Prostitution, 2, 14, 26, 35, 122, 276, 301, 303, 313, 330, 331, 334, 383 Protestant, 305

INDEX

Protomedicus , 46, 113, 115 Prussian model, 57 Psychiatric histories, 26 Psychiatric institutionalisation, 5, 9, 25, 370 Psychiatry academic, 193, 196 academic research in, 213 asylum, 12, 20, 225, 246, 247, 380, 381 biological, 11, 33, 34, 68, 198, 292 forensic, 66, 103, 175, 195, 202, 204, 226, 274 relationship with, 20, 195, 379 medicine, 20, 195 philosophy, 195 religion, 121 romantic, 10, 112, 135, 372 the scientific foundation of, 196 Psychoanalysis Chicago Institute of Psychoanalysis , 356 Columbia Psychoanalytical Institute, 356 Department and Clinic of Psychoanalysis, Budapest, 356 Fifth Congress of the International Psychoanalytical Association, Budapest, 1918, 352 Sigmund Freud, 1 See also Ferenczi, Sándor Psychoanalytical approach, 352 method, 355 Psychology, 1, 7, 10, 101, 109, 115, 135, 372. See also Experiment, experimental psychology Psychosomatic, 115, 345 Public asylum, 9, 11, 61, 62, 132, 136, 147, 149, 160, 162, 171, 172, 177, 178, 199, 292, 294, 295, 370, 374, 375

437

Public health care financing, 63, 374 the organisation of, 337 1876 Public Health Care Act, 60–62, 92, 95, 96, 167, 171, 172, 174, 188–190, 375 Punish/Punishment, 26, 29, 159, 268, 276, 277 Q Quacks, 36 Quaker, 29. See also Tuke dynasty R Race human, 341–343 hygiene, 343 preservation of the, 341 See also Breed/breeding Race Hygiene Inter-Association Committee/Egyesületközi Fajegészségügyi Bizottság, 343 Race preservation, 331 Radó, Sándor, 356 Rage/Raging bench, 161 patient, 161, 164, 165, 210, 211, 257, 372 Raisz, Gedeon, 260 Rákospalota Sanatorium, 66, 265, 270 Ramón y Cajal, Santiago, 217 Ranschburg, Pál, 217, 219, 226, 344 Ratio Educationis Publicae, 50 Raymond, Fulgence, 219 Red Cross, 103 Elisabeth Hospital of the, 103 Regeneration, 343 Regimen, 30, 36, 370 Religion/Religious and psychiatry, 121 background of patients, 295

438

INDEX

care for the insane, 9, 36 needs, 151 practice, 40, 121, 295 See Denomination Reproduction, 31, 69, 340–343 Reproductive organs, 302 influence of on the mental state, 14 Research experimental, 12, 33, 67, 193, 197, 198, 379, 381 laboratory, 12, 194, 198, 225, 380 scientific, 11, 67, 200, 228, 245, 379 university, 34, 197 Restraint bed treatment, 163 chemical, 162, 163, 373 no-restraint, 31, 32, 132, 133, 162, 164, 165, 246, 372 physical, 155, 162, 163, 373 strait-jacket, 161, 164, 209, 252, 372, 373 See also Coercion in asylums Riedl, Joseph Gottfried, 32, 149, 200, 213, 246 Ringelhann, Béla, 41, 83–85, 88 Ringer, Jen˝ o, 66 Ringer’s Sanatorium in Kelenföld, 66 Rivers, W.H.R., 355 Róheim, Géza, 356 Rokitanski, Carl von, 197–199, 246 Romanian, 294, 311 Romantic medicine, 114 psychiatry, 10, 112, 135, 372 Royal Mária Valéria Barrack Hospital , 352 Royal National Prison/Királyi Országos Gy˝ ujt˝ ofogház, 274 Royal Society of Pest Physicians, 52, 53

Rózsahegy Hospital, 349, 351 Russia/Russian, 52, 220, 258 Ruthenian, 295, 311 S Sachs, Bernard, 220 Saint John’s Hospital/Szent János Kórház, 59, 169, 170, 211 Saint Ladislas Hospital/Szent László Kórház, 59 Saint Margaret’s Hospital/Szent Margit Kórház, 59 Saint Roch Hospital/Szent Rókus Kórház (Observation Ward), 59 Saint Stephen’s Hospital/Szent István Kórház, 59 Salgó, Jakab, 58, 69, 143, 155, 159, 186, 191, 195, 224, 229, 241, 278, 288, 313, 322, 332, 358, 359, 374, 380 Salpêtrière (Paris hospice), 27, 29, 68, 213, 219, 223, 225 Sanatorium/Sanatoria Dr. Batizfaly’s Sanatorium and Hydropathic Institute in Budapest, 271 Dr. Glück’s Sanatorium and Hydropathic Institute in Városligeti Fasor, 271 for nervous ailments, 271 Niedermann’s Sanatorium in Rákospalota, 66 Park Sanatorium in Dunaharaszti, 271 people’s nerve-, 273 Svábhegy Sanatorium, 272 Városmajor Sanatorium and Hydropathic Institute in Buda, 271 See also Grünwald Sanatorium, Budapest Sántha, Kálmán, 220

INDEX

Sarbó, Artúr, 217, 219, 346, 347, 359, 365 Sátoraljaújhely colony, 262, 263 Saxon, 259, 260 Scandinavian, 258 Schaffer, Károly, 70, 194, 195, 203, 211, 214–220, 226, 227, 229, 231, 232, 234, 236–244, 295, 359 Schelling, Friedrich Wilhelm Joseph, 114 Schnirch, Emil, 22, 58, 152 School for the Deaf and Dumb, Vác/Siketek Nevel˝ oháza/Royal National Deaf and Dumb Institute, 264 Schorske, Carl, 3, 4 Fin-de-Siècle Vienna: Politics and Culture, 3 Schrapnell , 346 Schreiber, Imre, 165 Schwartzer Asylum, 47, 106, 134, 153, 166, 201, 202, 247, 298, 309, 315, 317, 371, 380 Schwartzer dynasty, 106, 134, 153, 166, 371, 380 Alajos, 102 Antal, 102 Ferenc I, 102 Ferenc II, 102 Ferenc III, 102, 103 Schwartzerian, 154, 155, 373, 374 Scientific psychiatry university psychiatry, 11, 12, 193, 199, 381 See also Academic psychiatry Sclerosis multiplex, 219 Scotland/Scottish, 111, 255, 258, 260, 269 Scull, Andrew, 5, 73–78 Sedatives, 110, 111, 155, 162, 163, 209, 254, 347, 381

439

Semmelweis Museum, Library and Archive, 6 Serb/Serbian, 133, 294, 295, 311 Sex/Sexual abuse, 345, 355 perversion, 330 promiscuity, 301, 334 Shell shock traumatic neurosis, 344 See also War neurosis Shock, 128, 349, 350, 354 Shorter, Edward, 23, 72, 140, 185, 231, 278, 323 Showalter, Elaine, 75, 297, 325 Simmel, Ernst, 355 Simulation, 315 Sisters of the Hospitaller Order, 157, 370 Skoda, Joseph, 198, 362 Skull, 31, 118 Slavic, 54, 92 Slovak/Slovakia, 2, 55, 294 Slovene, 295 Social disparity, 310 hygiene, 43 medicine, 330 standing/status, 6, 130, 131, 309 Socialism, 14, 329 Somatogenic, 346 Soul, 12, 22, 36, 40, 101, 109, 116, 123, 124, 127, 130, 154, 166, 225, 260, 338, 344, 370, 382 Spain/Spanish, 23, 217 Specialised institutes for alcoholics, 13, 66, 263, 378 for criminals, 13, 66, 264, 378 for epileptics, 13, 66, 263, 378 for ‘idiot children’, 13, 66, 263, 266, 378 for ‘imbeciles’, 66, 166, 263 for nervous patients, 134, 271, 272

440

INDEX

Statistics, 11, 14, 107, 204, 205, 291, 292, 295, 302, 308, 321, 357 asylum, 7, 13, 58, 64, 66, 159, 162, 313, 315, 317 Stein, Fülöp, 271, 337 Steinhof, Am, 32, 251 Stifft, Joseph Andreas, 52, 113, 114, 116 St. Luke’s Hospital, 28 Stoll, Maximilian, 113, 114 Strait-jacket coercion, 132 See also Restraint Strobl, Villibald, 250, 268, 270, 279, 280, 286 Struggle for existence, 331 Strümpell, Adolf, 220 Suggestion negative, 222, 240 power of, 223, 348 verbal, 222, 349, 350 Suggestive therapy, 226 Suicide, 14, 122, 124, 162, 261, 303, 329, 340 Svábhegy Sanatorium, 272 Swabian, 148 Sweden, 258 Switzerland/Swiss, 32, 162, 256, 264, 379 Symptom, 1, 33, 40, 111, 118, 167, 195, 198, 199, 269, 275, 304, 313, 317, 333, 334, 338, 344, 345, 347–349, 351, 353–355 Syphilis/Syphilitic, 14, 303, 317, 321, 330, 331, 335, 341, 377 patients, 43 Szapáry, Count Ferenc, 114 Szárics, Jen˝ o, 142 Szász, Thomas, 25, 73 Széchenyi, Count István, 31 Székely Land/Szeklerland, 260 Szigeti, Henrik, 175, 191

T Tangl, Ferenc, 218 Taxonomy of diseases, 119 problematic, 313 See also Mental illness/disease/disorder, forms of Tay-Sachs/Tay-Sachs-Schaffer disease, 220, 295 Tay, Waren, 220 Teaching hospitals, 33 medical, 23, 33, 44, 47, 48, 52, 54, 67 psychiatric, 2, 200, 202, 227 See also Medical faculty Telegdi, Zsigmond, 174, 191 Temperament, 110, 117, 118 constitution, 116, 117 Textbook in forensic psychiatry, 195 in mental pathology, 195 university, 195 Therapeutic nihilism/pessimism, 12, 34, 248 optimism, 28 Therapy/Treatment electric, 347, 351 free, 35, 159, 161, 374 moral, 10, 29–31, 101, 155, 166, 373 occupational, 31, 149 physical, 127 psychic, 126–128, 131 suggestive, 226, 347 work, 11, 13, 66, 206, 255, 270, 374, 378 Tollhäuser, 27 Torture, 349 Transylvania/Transylvanian, 45, 56, 58, 152, 166, 217, 249, 260,

INDEX

292, 293, 295, 296, 298, 305, 307 Trauma traumatic neurosis, 344, 345, 349, 351, 353 war neurosis, 15, 333, 345, 346, 348, 352–355, 357, 383 See also Shell shock Trefort, Ágoston, 202 Tuberculosis/Tuberculotic, 13, 156, 256, 261, 270, 374 Tuke dynasty Samuel, 30 William, 30 Turkey/Turkish, 121 Turnowszky, Mór, 269

U Unitarian, 307 United States of America/American, 264, 342 University clinic, 11, 20, 66–68, 196, 199, 203, 206, 211, 213, 215, 226–228, 248, 316, 379, 381, 382 Department and Clinic for Mental and Nervous Pathology, Kolozsvár (Cluj), 250 Department and Clinic of Mental Health and Pathology, Budapest, 68, 103, 194, 196 scientific psychiatry, 196 university psychiatry, 12, 198, 199, 381 See also Academic psychiatry Urbanisation, 61, 299 Uterus/Uteral Mother, 316 See also Hysteria/Hysteric

441

V Vác Royal National Institute for the Deaf and Dumb, 102 Váczi Street Military Hospital, 346 Vagabondism, 332 van Swieten, Gerard, 33, 47, 112 Városmajor Sanatorium and Hydropathic Institute, Buda, 271 Verubek, Gusztáv, 162, 186 Verwirrtheit, 315 Vienna/Viennese art, 3 First Vienna School, 33, 112 General Hospital, 32, 51, 112 Medical Faculty, 31, 47, 198 medicine, 33, 113, 115 modernism, 3 Neurological Institute, 217 Second Vienna School, 33 University, 197 Virchow, Rudolf, 198, 362 Viszanik, Mihály, 31, 200 von Feuchtersleben, Ernst, 116

W War neurosis traumatic neurosis, 345, 347–349, 351–354 See also Shell shock Weisz, Ármin, 348, 349 Wenckheim, Béla, 22 Wernicke, Carl, 34, 199, 215 Westphal, Carl Friedrich Otto, 34, 68, 199, 201, 215, 216, 317 Whiggish historiography, 25, 26 Whytt, Robert, 111 Wosinszki, István, 267, 268, 270 Epileptic Colony in Balf, Hungary, 270 Wundtian laboratory, 226

442

INDEX

Y York Asylum, 29, 30

Z Zombory, Gusztáv, 72, 151, 181, 186