Bulletin of the History of Medicine

Gymnastics by the Lake: Übungstherapie at the Kurort

Foerster learned about and adopted Übungstherapie during a stay with Heinrich Frenkel (1860–1931) in Heiden, Switzerland. Frenkel, himself trained in neurology under the neurological internist Wilhelm Erb at Leipzig University, had moved to Heiden in 1884 to open a clinic specializing [End Page 106] in neurological gymnastics.¹⁷ Übungstherapie, then, first took root outside the boundaries of the university or city hospital, in the peripheral medical space of the Kurort.

The Kurorte in the German-speaking world rose to prominence over the course of the nineteenth century to cater to the rising urban middle and upper classes. Often located at some distance from the larger cities, Kurorte, comprising Kurhotels (hotels for Kurort patients), rest homes, and sanatoria, provided privately run health care in a bucolic setting. Often situated in the mountains or some spa town, the Kurorte mixed recreation and medicine.¹⁸ For instance, the Kurort of Heiden, where Frenkel worked, was a small Swiss village overlooking Lake Constance. Patients could stroll around the Bellevue- Spazieranlage, take excursions around the lake, or make use of one of the three baths in the village.¹⁹

The duration of a cure made it prohibitive to all but middle- and upper-class patients, both financially and in terms of the time commitment; a visit to a Kurort was a gentrified affair.²⁰ It is for this reason that treatments, which otherwise had difficulty gaining institutional support in state hospitals, and might be considered marginal, could find in the Kurort a receptive group of patients willing to pay. Indeed, in many ways Übungstherapie as practiced by Frenkel required the resources available at the Kurort. Übungstherapie involved daily exercise sessions that had to be closely supervised by the physician over extended periods of time. As Frenkel pointed out, the treatment “demanded the physician’s full attention” and could hardly be performed in the context of a nonprivate hospital, where time was short and other duties pressing.²¹ Moreover, [End Page 107] Übungstherapie was a treatment that required, at least in the format Frenkel practiced, room for movement. As opposed to the often-cramped quarters of state hospitals, the Kurorte abounded in space. Frenkel stipulated that the Übungsraum (exercise hall) should be twenty meters long to avoid excessive turning during the walking exercise.²² He was able to commandeer a bowling alley in one of the taverns of the building that had become his clinic to use as an exercise hall.²³

For practitioners, then, alongside the obvious financial appeal, the Kurort was attractive for the space and time it allowed for medical practice. Even though a position at the Kurort held less prestige than a university post, and research was performed in doctors’ free time, practitioners like Frenkel still participated in scientific exchange. Frenkel’s publications were received in wider academic circles,²⁴ and, after having practiced in the Kurort for almost two decades, he was able to obtain a position at the Charité hospital in Berlin in serological medicine, an up-and-coming area of medical research and therapeutics at the time.²⁵ Some practitioners, such as the prominent ophthalmologist Albrecht Graefe, himself benefiting from the climate to treat his tuberculosis, combined practicing at the Kurort with their academic work, and young physicians like Foerster went to study there as well.

If the Kurorte were welcoming locations for Übungstherapie, the 1880s and 1890s (when Frenkel practiced there) were also a receptive time. In the last decades of the nineteenth century, “nervousness” had become epidemic in Western society. The newly described disease of neurasthenia had become prevalent in European cities where the general increase of speed of life and the impact of new technologies were taking their toll on the nervous system.²⁶ The quiet setting of the Kurort was thus considered as suitable base for the treatment of nervous disease.

Like many other Kurorte, Heiden had a longer tradition as a healing center. Since the mid-nineteenth century it had been host to a variety [End Page 108] of different treatments: the above-mentioned ophthalmologist Albrecht Graefe had practiced in Heiden in the summers, while other patients made the trip to Heiden for the Molkekur, a regimen of fresh goat or herbal whey, whose regular consumption was considered to have purgative as well as nourishing effects.²⁷ But, toward the end of the nineteenth century, the Kurorte came to be seen increasingly as places to treat diseases of the nervous system; nervous pathology crowded out the more varied illnesses of an earlier era. For example, the Wasserheilanstalten (water cure clinics), where patients would apply mineral water both internally and externally, originally treated a variety of ailments. As the railways connected them to industrial centers from midcentury onward and their popularity boomed, they underwent a subtle transformation. By the 1910s, most Wasserheilanstalten not only predominantly treated nervous patients; a large number had been rebranded as Nervenheilanstalten (nervous clinics).²⁸

At the time, another previously dominant treatment was losing ground. Publicized by the American neurologist Silas Weir Mitchell in the 1870s and introduced into Europe a decade later, the rest cure aimed to give patients complete isolation, peace, and quiet. The cure was based on the assumption that certain activities depleted the nervous system of its energy. Although the cure was at first very successful, there was increasing skepticism about its efficacy among medical practitioners, including Frenkel. The internist Ernst Leyden observed in 1885 that “extended muscular rest weakens the energy and coordination of muscles and . . . such patients, if they had stayed in bed for 8 or 14 days, could hardly walk or stand.”²⁹ In fact, “energetic people, who walk a lot, preserve their muscular force longer and better than the softish and un-energetic; for this reason women, when they fall ill with tabes, usually lose their muscular force more quickly.”³⁰ The solution then was to get patients out of bed, and make them move in specific ways.

Exercises in Therapy: The Therapeutic Appropriation of Gymnastics in Germany

Übungstherapie was plausible, among other things, because in neurologizing gymnastics Frenkel participated in broader trends of nineteenth-century [End Page 109] Kurort medicine. It also drew on a long tradition of therapeutically inclined gymnastics. Indeed Frenkel’s Übungstherapie was only one of a number of forms practiced at the Kurort, which offered a range of treatments such as Zander mechano-therapy and Swedish-style Heilgymnastik (therapeutic gymnastics).³¹

German medical gymnastics finds its roots in the broader Turnen (gymnastics) tradition. The German Turnbewegung (gymnastics movement) emerged on the cultural scene in the Napoleonic Wars. It was a nationalistic enterprise, provoked by Napoleon’s invasion of the Holy Roman Empire in the first years of the nineteenth century. From the beginning, with the 1811 foundation of Turnvater (lit. “father of gymnastics”) Friedrich Jahn’s gymnastics center at Hasenheide in Berlin, Turnen attracted a generation of young men who looked to connect with a broader German spirit. Despite these nationalist beginnings, Turnvater Jahn’s movement did not initially find a receptive political environment in Germany. In the fragmented German-speaking lands, Jahn’s nationalist message was ill received by elites, and the egalitarian ethos of Turnen made it easy to depict as a revolutionary threat. After it became known that the book burning at the Wartburg Festival in 1817 had been orchestrated by Hans Ferdinand Maßmann, a key figure in the Turnbewegung, the Turner (gymnasts) began to be grouped alongside other revolutionary and dangerous forces. Alongside Burschenschaften (fraternities), the universities, and the press, the gymnastics movement was put under scrutiny, and targeted explicitly by the Carlsbad Decrees (1819). Turnen was banned, and the Hasenheide was closed in 1819; Jahn himself served six years in prison. Nonetheless, the Turnbewegung was revived in the 1830s and 1840s and remained influential throughout much of the remaining century, gaining greater political legitimacy due to the renewed place of nationalism in the German unification project in the period after 1848.³² In fact, the gymnastics movement spread all over the German lands; by the mid-1860s, [End Page 110] the future German Reich could boast two thousand gymnastics clubs with almost two hundred thousand members.³³

For a German in the late nineteenth century, therefore, Turnen would have been a recognizable part of the cultural landscape. Of importance for us, two aspects in particular marked the practice. First, since its earliest origins, Turnen was distinctly militaristic. Exercise such as wrestling and fencing, mounting leather horses, and “storm running” through difficult terrain served to prepare the gymnasts for future combat.³⁴ Second, Turnen was understood as a predominantly social affair. Indeed, for Jahn, gymnastics helped create not only national, but social unity. As the Turnpädagoge (teacher of gymnastics) Carl Euler noted in 1881, quoting the gymnast Eduard Dürre, “He [Jahn] wanted to unite those who were separate, avoid antagonism, and awaken public spirit [Gemeinsinn] in the youth of that people, which should shake off its heavy shackles.”³⁵ Be it through joint exercises at the Hasenheide, or singing and hiking on the Turnfahrten (gymnastic journeys), the group activities of the gymnasts promoted solidarity across diverse social origins—the participants in Jahn’s Turngesellschaft (gymnastic society) came from various different social strata—as well as national feeling.

A corollary of this social element, Turnen, though ostensibly physical, was understood to have a beneficial effect on the moral character of its participants. In the Napoleonic context, Jahn considered that active and strong-willed young men were crucial to the liberation of Germany, and Turnen was a valuable exercise in promoting these qualities. As Jahn pointed out in his 1816 Die deutsche Turnkunst, performing a difficult physical exercise “brings the will past the false paths of transient, arbitrary desire [Willelei] to consistent will [Wille], to the perseverance which is the basis of every victory. You carry a godlike feeling in your breast from the moment you first recognize that you can do something if only you will it.”³⁶

From the midcentury onward the therapeutic aspect of Turnen came to the fore; gymnastics was medicalized. Most forms of the emerging medical gymnastics demarcated themselves from the radical Turnbewegung by rejecting its nationalist elements. For example, Swedish-style medical gymnastics, introduced into Germany by the Prussian army officer [End Page 111] Hugo Rothstein, was self-consciously nonnationalistic, priding itself in its strictly physiological orientation.³⁷ Nonetheless, it still found its earliest proponents outside the medical profession, with educators and military personnel. Rothstein was sent by the Prussian war minister Hermann von Boyen to Stockholm to take a complete course at the Swedish proponent of Heilgymnastik Pehr Henrik Ling’s institute in the early 1840s. Upon his return to Berlin, he opened the Central-Institut für den gymnastischen Unterricht der Armee (Central Institute for the Gymnastic Education of the Army). The institute, after closing in the revolutionary year of 1848 and reopening shortly thereafter, trained members of the military and gymnastics teachers for schools.³⁸

By the late century, Heilgymnastik also began to make inroads into institutionalized medicine. For example Moritz Michael Eulenburg, who, like Frenkel, worked in a private clinic, built upon the physiological orientation of Ling’s system. Eulenburg explained the beneficial effects of gymnastics by referring to its physiological action: increased metabolism, muscle strengthening, and the stimulation of sensory nerves. But what made his particular variant of Heilgymnastik ultimately successful was its marriage with an orthopedic impulse. When Eulenburg aligned his medical approach to gymnastics with orthopedics, he built allegiances with a powerful and growing fraternity of specialist doctors, lending his approach further legitimacy.³⁹

Frenkel’s Übungstherapie

As a physician in the Kurorte, Frenkel situated himself outside the medical mainstream, like Heilgymnastik.⁴⁰ Moreover, his Übungstherapie found [End Page 112] receptive ground in the Kurort because it was recognizable within the broader cultural tradition of Turnen.

First, Übungstherapie recalled the emphasis on moral edification and strengthening of the will that was central in the German gymnastics movement. It was, Frenkel asserted, effective “not in the muscle work but in the repetition of a willed active movement.”⁴¹

Second, though understood as neurologically beneficial, Übungstherapie comprised a series of repetitive and clearly defined movements. Because the patients lacked complete control over their limbs, the movement needed to be directed clearly by the physician. Like those participating in Jahn’s Turnen or Rothstein’s Heilgymnastik, Frenkel’s bourgeois patients practiced military-style drills. The drill-like nature of the movements was embedded in the practice: patients often had to exercise specific movements upon the command of the physician. The doctor would clap his hands in a certain rhythm, or call out to the patient “march” or “turn”—vocabulary taken from the parade ground—to initiate and time the patient’s movements.

The militarist element in Frenkel’s practice should not be overestimated. As suggested above, an important rationale for his practice was based on the reestablishment of the connection between volition and kinesthetic ability. But the material culture in Heiden suggests that a certain military uniformity marked Frenkel’s gymnastic practice. To determine the movements, Frenkel used a range of apparatuses, such as floor paintings that would indicate the length of a step (Figures 1 and 2). The physician would call out specific numbers relating to positions marked on the floor (“left forward 3” or “right sideways 1”).⁴²

In Figures 1 and 2, we see the measured distance of steps that the patient was supposed to take. One full step was 63 centimeters in length; a 30.5-centimeter distance represented a half step; a “small step” or quarter step measured about 15 centimeter. Frenkel included the exact measures of his floor paintings and apparatuses in his handbook to ensure consistency in other clinics. For his “foot prints” (Fußspuren) and “floor cross” (Bodenkreuz), not only the length of the steps but also the position of the feet were specified (see Figure 2). [End Page 113]

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Figure 1.

Patient practicing Seitwärtsgang (sidestep). Heinrich Frenkel, Die Behandlung der tabischen Ataxie mit Hilfe der Übung (Leipzig: Vogel, 1900), 212.

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Figure 2.

Floor drawings. Heinrich Frenkel, Die Behandlung der tabischen Ataxie mit Hilfe der Übung (Leipzig: Vogel, 1900), 152ff.

Third, like Jahn’s Turnen, Frenkel’s Übungstherapie was often a group exercise. The strategy was to discipline the movements of participants by forcing them to fit into a synchronized muscular action. In the group exercises illustrated in Figure 3, three men stood in a row moving concurrently, either according to the physician’s command or according to [End Page 114] the “wingman’s” (Vordermann) order (note the military language). If the wingman was leading the exercise, he had to be healthy or almost healthy to ensure smooth action. He was executing the order, “changing the speed of the movements . . . according to his own will, at times moving quickly, at times slowly. . . . His followers have to follow his example faithfully.”⁴³

As is evident from the photographs, for the other two men every movement was exactly determined by where the “wingman” set his feet or moved his arms. Conversely, the patient’s own movements determined and freed up the space for the movements of the others. If he did not move correctly, the group exercise would not function. Frenkel drew attention to this responsibility of the individual for the group: the intended movement was “only possible if all three men [Übenden] set their legs into motion simultaneously, as the following has to step onto the position of the front man.”⁴⁴ Like in German gymnastics, we see how in Frenkel’s Übungstherapie the individual negotiated her place within a social whole; she had to subordinate herself to the dominance of the group, directed by the supervising figure of the physician.

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Figure 3.

Group Übungstherapie. Heinrich Frenkel, Die Behandlung der tabischen Ataxie mit Hilfe der Übung (Leipzig: Vogel, 1900), 242ff.

[End Page 115]

Frenkel’s success at the Kurort was explicable in part by his ability to render Übungstherapie recognizable to his predominantly bourgeois class of patients. In more mainstream medicine, however, there was initially no place for it—despite the fact that Frenkel was originally trained in that tradition, and remained an active participant in scientific exchange. To understand this initial lack of interest, let us turn to the history of neurology in the German-speaking world.

History of Neurology in the German-Speaking World

Neurology in the German-speaking world was for much of its history caught between psychiatry and internal medicine. The first neurological textbook Lehrbuch der Nervenkrankheiten was published in 1840 by Moritz Heinrich Romberg, an internist at the medical polyclinic at the Berlin Charité hospital. At around the same time, Wilhelm Griesinger published his own textbook (Pathologie und Therapie der psychischen Krankheiten) that was to become the bible for the neuropsychiatrists. Here he made his signature claim that “mental disease [was] brain disease.”⁴⁵

Griesinger’s approach won out.⁴⁶ He succeeded Romberg in Berlin, simultaneously holding the chair of psychiatry and running a neurological department from 1865. It was the first combined neuropsychiatric chair in Germany.⁴⁷ Over the next few years, the Griesinger model was increasingly put into action. Integrating the neuropathological study of the nervous system into their approach to mental illness helped such academic psychiatrists as Theodor Meynert, Carl Wernicke, Karl Bonhoeffer, and Karl Kleist to demarcate themselves from asylum psychiatrists. They [End Page 116] provided a somatic understanding of mental pathology at a time when somaticism was becoming hegemonic in medicine. As Eric Engstrom has observed, a marker of this development was the insertion of the word “nerve” into the name of psychiatric journals and societies: the Berliner medicinisch-psychologische Gesellschaft became the Gesellschaft für Psychiatrie und Nervenkrankheiten in 1879.⁴⁸

Psychiatry’s new orientation, embracing neurological language and methods, elicited considerable resistance. The neurological internists Wilhelm Erb and Adolf Strümpell expressed their resistance to the “increasing usurpation by psychiatrists of nervous disease.”⁴⁹ Together with Friedrich Schultze and Ludwig Lichtheim, in 1891 they founded the Zeitschrift für Nervenheilkunde, in which they promoted a neurology that was oriented toward internal medicine. In 1904, at the Twenty-Ninth Congress of Southwest-German Neurologists and Psychiatrists (Wanderversammlung der Südwestdeutschen Neurologen und Irrenärzte) in Baden-Baden, the debate culminated in an open conflict between the neurological internists Schultze and Erb and the psychiatrists Karl Fürstner and Eduard Hitzig, with both sides claiming neurology for themselves.⁵⁰

Despite the opposition, the institutional dominance of psychiatrists within the field of neurology seemed unstoppable. In Berlin and Halle, two of the leading universities in Prussia, chairs went to professors who preached the unity of the two: Friedrich Jolly and Eduard Hitzig. The trend for combined neuropsychiatric university clinics continued in the early twentieth century in Greifswald (1905), Göttingen (1906), Breslau (1907), and Bonn (1908). Even in institutions where neurology had already been established in independent form—Breslau, Hamburg, and Heidelberg—additional neuropsychiatric clinics were founded.⁵¹

The relative success of the psychiatrists helps explain why Frenkel might have looked beyond academic medicine, to Kurort medicine, to establish his neurological gymnastics. As we have seen, Frenkel was trained in the internal neurological tradition, for which, in the 1880s, the future did not look particularly bright, and his emphasis on lower functions was out of place in the dominant neuropsychiatry.

But it also helps explain Frenkel’s eventual return to the academic sphere. One of the major arguments by the psychiatrists against an [End Page 117] independent neurology was its lack of a specialized treatment.⁵² In 1915 Karl Bonhoeffer, then Ordinarius (full professor) for psychiatry and neurology in Berlin and at least institutionally the most powerful psychiatrist in Germany, argued that “the development of a specialized examination and therapeutic technique led to the separation of otology, laryngology and orthopedics from surgery.” Similarly, the “practical importance of infant care (Säuglingsfürsorge)” had led to the separation of pediatrics from internal medicine.⁵³ Therapeutic application was a precondition for institutional autonomy. Neurology, in Bonhoeffer’s eyes, could not furnish a therapy that would justify its independence. Of the treatments it did offer, none was specific to it: neurosurgery could be performed satisfactorily by general surgeons who had “learned the ropes of the specialty” and neurology’s second big area of treatment, electrotherapy, to Bonhoeffer, was a “disputable field with respect to organic effectiveness.”⁵⁴

While Bonhoeffer criticized the therapeutic poverty of neurology, it was precisely the field’s growing therapeutic arsenal that appealed to neurological internists. At first, when Frenkel presented his method at the Sixty-Third Congress of German naturalists and physicians (Versammlung deutscher Naturforscher und Ärzte) in 1889, the impact was limited.⁵⁵ But in 1892 the medical heavyweight Ernst Leyden singled out compensatory medical gymnastics as a highly promising approach to the treatment of movement disorders in tabes, and identified Frenkel’s Übungstherapie in particular as “remarkable,” “astute” and, in its success, “thankworthy” (dankenswert).⁵⁶ Consequently, interest in the treatment grew. In 1897, Frenkel presented his work at the Twelfth Congress of Medicine in Moscow, and his presentation was among the most discussed and best attended of the meeting.⁵⁷ It was due to Frenkel’s success that Foerster was sent by [End Page 118] his Klinikdirektor (clinical director) Carl Wernicke to Heiden in 1897 to complete his neurological education.⁵⁸

The reputation that Frenkel had built through his Übungstherapie allowed him to return to medical research. In the early years of the new century, he gained a position in the serological department at the Charité hospital in Berlin.⁵⁹ It is significant, however, that Frenkel had returned into the mainstream not as a neurologist, but as an expert on the internal aspects of syphilis; consequently he left the neurological Übungstherapie behind at the Kurort. Neurology would emerge as an independent specialty in large part through the work of a man trained instead in the neuropsychiatric tradition: Otfrid Foerster.⁶⁰

Otfrid Foerster: Neurological Gymnastics at the City Hospital

From his return to Breslau from his training in Heiden with Frenkel in 1899 until 1904, Foerster worked as an assistant to the neuropsychiatrist Carl Wernicke. Foerster’s early work was much in the spirit of Wernicke’s psychiatry: Foerster’s early papers touched on topics such as the compulsive reproduction of memory images, cortical paralysis of touch (corticale Tastlähmung), and the somatopsychoses.⁶¹ After writing his Habilitation under Wernicke in 1903, Foerster gave his inaugural address as Privatdozent (lecturer) on “Comparative investigations of motility psychoses and diseases of the system of projection fibers,” a topic recognizably marked by Wernicke’s system.⁶² [End Page 119]

It was during this time that Foerster started publishing widely on Übungstherapie and the coordination of movement more generally. Indeed, his early work on Übungstherapie helped establish his reputation within medicine. Foerster often took his patients to scientific and medical congresses to demonstrate the technique.⁶³ In 1904, for instance, he presented a case treated by Übungstherapie before the prestigious Gesellschaft Deutscher Naturforscher und Ärzte. The patient, a thirty-eight-year-old worker, had severe hemiplegia, but four years of Übungstherapie enabled him to walk, run, button up his clothes, and write again.⁶⁴ Furthermore, Übungstherapie was central to Foerster’s teaching. After gaining his Habilitation in 1903, Foerster’s “Course on Übungstherapie for Nervous Diseases” became a permanent institution at the university.⁶⁵

When Foerster ventured into other therapeutic areas, Übungstherapie remained an important element of his clinical practice. Übungstherapie was most prominent in his work as a complement to surgery on the nervous system. In the first decade of the twentieth century, Foerster had become increasingly interested in using surgery to treat neurological disease. In the hospital context, in cooperation with the Breslau surgeons Alexander Tietze and Friedrich Küttner, Foerster developed an operation to treat spastic paralysis in patients with Little’s disease, which later became known as the “Foerster operation.”⁶⁶

Little’s disease was generally seen as one of the worst of all childhood afflictions. Patients spent their lives immobile and dependent, lying bent in their beds or sitting on their chairs in contorted positions. According to Foerster’s coworker Tietze, “with their crooked, spastically contracted [End Page 120] limbs” they were “truly pitiful creatures.”⁶⁷ There was little therapeutic hope for these patients. Indeed, in his 1897 monograph Die infantile Cerebrallähmung, Sigmund Freud had called the treatment of the disease a “miserable and hopeless [trostloses] chapter,” dedicating only three out of three hundred pages to the discussion of its therapy.⁶⁸

Foerster’s operation, first (in 1907) carried out by Tietze or Küttner under Foerster’s guidance, later (in the 1910s) performed by Foerster himself, was extremely effective. Almost 80 percent of the children operated on showed clear signs of improvement. In the 1910s, the operation gained wide acceptance within the medical community inside and outside Prussia.⁶⁹ The operation was, however, successful only if combined with Übungstherapie. Surgery, although therapeutic, inflicted considerable damage to the nervous system so that it had to be reconstituted by months of pain-staking exercises. Foerster’s neurosurgery, his greatest achievement in the eyes of many, in particular his Anglo-American colleagues,⁷⁰ can be fully understood only within the context of this broader therapeutic regime.

As Übungstherapie was integrated into a more academic medical context, the practice changed in subtle ways. We have seen that in Frenkel’s practice the patient’s movement was often guided by a set of external apparatus—the footprint on the floor, or the moving body besides the patient, which the patient had to imitate. Foerster, on the other hand, dispensed with all these instruments. For the successful treatment of the ataxic patient, no special apparatus was required: “With a few chalk marks, one can always and everywhere improvise whatever is necessary. I have attained the same good results in the humble attic of the day laborer as in the gymnasium where the patient worked on complicated apparatuses.”⁷¹

Indeed, for Foerster, certain apparatuses not only were inefficient (patients, after mastering the task at the instrument, would not be able to retain what they had learned outside the exercising context) but could impede the process of recovery. Instead of relying on the support of a mechanical instrument, the patients should learn to mobilize their own [End Page 121] forces, with the watchful physician present at all times to correct any wrong movement and to catch the patients if they fell.

In part, Foerster’s sidelining of instrumental assistance grew out of the economic limitations of his position; ironically, as Übungstherapie began to become more institutionalized, there was, at least in the beginning, less financial support. Foerster’s professional situation—from 1903 to 1909 he worked as unsalaried Privatdozent—did not allow him to create the extensive material culture that Frenkel and others used for their treatment in the relatively well-resourced Kurorte. Moreover, he faced spatial limitations. His neurological unit at the Agathstiftung had merely fourteen beds.⁷² He therefore was forced to develop less elaborate means for practicing Übungstherapie.

In its more institutionalized context in the hospital, Übungstherapie became more improvisational. Foerster made do with the spaces he found around him in the patients’ home and in the hospital, without being able to transform them permanently as Frenkel had done. With fewer resources materially, spatially, and financially, Foerster’s Übungstherapie was forced to adopt a greater flexibility and simplicity. His particular version of Übungstherapie became less prescriptive than Frenkel’s; the militarist element which for Frenkel had contributed to the cultural plausibility of the technique was lost in the context of the Breslau hospital.

Building a Specialty

For Foerster, this unorthodox turn to treatment became the key to his professional success. First, the therapeutic aspects of his work allowed Foerster to knit his neurology into the larger ecosystem of early twentieth-century hospital medicine. Foerster secured trans-specialty relationships not only in his local cooperation with surgeons, but also by presenting his work at orthopedic and surgical congresses and publishing in orthopedic and surgical journals;⁷³ he became a member of the Deutsche Gesellschaft für Orthopädische Chirurgie (German Society for Orthopedic Surgeons) in 1908.

Second, by being able to treat patients, Foerster gained institutional power. Foerster’s first institutional foothold was a small in-patient ward (Bettenstation) at the Agathstift, across the street from the Breslau Allerhei-ligenhospital [End Page 122] and part of the neurological Abteilung (department) that he was granted in 1911. Even though these spaces were quite simple,⁷⁴ their very existence was a sign of his success: the department was one of only a few independent neurological departments in the country.⁷⁵

When war broke out in 1914, Foerster was made consulting physician of the Sixth Army Corps and head physician of the Festungslazarett (military hospital) in Breslau, a position that he kept until 1920.⁷⁶ During the four years of conflict Foerster treated thousands of gunshot injuries to the nervous system. He reported almost four thousand cases of war-related peripheral lesions and almost four hundred cases of lesions to the spinal cord.⁷⁷ The expansive experience during the war gave Foerster, who had never formally trained as a surgeon, legitimacy for his operative interventions on the nervous system. His presentations on this work at the two war meetings of the Gesellschaft Deutscher Nervenärzte in 1916 and 1917 were prominent contributions and helped secure his reputation as a neurologist cum neurosurgeon.⁷⁸

In Breslau, in large part due to his increasing patient numbers, and despite budget constraints after the war, Foerster was able to commandeer ever more resources to support his work.⁷⁹ In 1920, the city authorities recognized that Foerster’s space at the Allerheiligen hospital was too limited, and he was offered new rooms in the Wenzel-Hancke hospital, located in the southern new part of Breslau.⁸⁰ Even after his move to the more [End Page 123] spacious premises, Foerster continuously asked for more beds and more personnel, that is, assistant doctors, nurses, and technicians.⁸¹ Moreover, he was not shy about seizing any and every opportunity to improve his working conditions. For example, in 1921 he asked for an empty room in the basement of the hospital, just below his department, “for the installation of electrical apparatuses” and to use the power supply of that room for his experiments.⁸²

A sign of Foerster’s increasing reputation was the 1919 offer of the newly created Ordinariat für Nervenpathologie (chair for neuropathology) at Heidelberg. The offer initiated a bidding war between Breslau and Heidelberg. The medical faculty at Breslau “placed great value on keeping Professor Foerster for the city of Breslau” and made him both Primärarzt (senior physician) for neurology (Neurologie) at the Allerheiligen hospital, and Ordinarius for neurology at the University of Breslau.⁸³ As a result of these negotiations, he was granted a “disposition fund” (Dispositions-fond) that put him in a better financial position than most other department chairs.⁸⁴ The transfer of Foerster’s Abteilung to the Wenzel-Hancke hospital in 1921 as well was a consequence of Foerster’s new sought- after status.⁸⁵

The building and opening of the Neurological Institute at Breslau in 1934 under Foerster’s direction can perhaps be seen as the culmination of Foerster’s professional success. Funded by both the Rockefeller Foundation and the Prussian state and Breslau city government, the institute was a remarkable achievement during a time otherwise characterized by belt-tightening. Germany’s economy had been hit hard by the 1929 Wall Street Crash, because of its dependence on U.S. loans. The unemployment rate rose exponentially, until, by the beginning of 1933, it had reached six million, affecting one-third of the working population.⁸⁶ Furthermore, as Foerster pointed out to Daniel O’Brien, his contact at the Rockefeller Foundation, in December 1931, Breslau had suffered particularly badly [End Page 124] during the depression.⁸⁷ The economic troubles did place constraints on the new institute. Money had to be saved at various levels; the building was built of simple brick and stone, furnishing was of the simplest though functional kind.⁸⁸ But that it existed at all was a testament to Foerster’s growing reputation.⁸⁹

It was planned to be predominantly a research institute. But it is important to recognize that the Rockefeller Foundation was interested in funding the project because of Foerster’s reputation, which was built largely upon his therapeutic successes.⁹⁰ Foerster’s linking of science and the clinic in the institute was also instantiated in the spaces of the new building. The new laboratory building was to be connected to ward 8 of Foerster’s neurological department; the elevator in the new building was spacious enough to accommodate patients transported in their beds.⁹¹ Patients were to be moved from their ward in the Wenzel-Hancke hospital to examinations rooms, or the patient demonstration room (Demonstrationssaal) on the top floor.⁹² The spaces of Foerster’s clinic proper were similarly filled with research materials and patients alike: Foerster’s international visitors had to be accommodated on the premises, and often that meant impinging on clinical spaces. Wilder Penfield, later director of the Montreal Neurological Institute who worked with Foerster in 1928, was assigned a workstation, which was called “the berth” (die Koje). It occupied a corner of the dayroom (Tagesraum) of the women’s ward, separated only by a small mobile partition.⁹³ Brain specimens and research instruments [End Page 125] were scattered around the clinic. Foerster also used the Tagesräume of his wards to hold meetings, to show his medical photographs and films, and even to perform animal experiments.⁹⁴

Foerster used his own professional success as a model for the development of neurology in Germany more widely. Just as his new treatments had helped garner the institutional support for establishing a neurological clinic and then a Neurological Institute in Breslau, so too could the exploitation of neurology’s therapeutic potential underwrite its independence from psychiatry. As Foerster’s position became stronger locally, he became a spokesperson for the developing field: in 1913 he was made coeditor of Deutsche Zeitschrift für Nervenheilkunde—the first German neurological journal, founded in 1891 by Wilhelm Erb; in 1919, Foerster also became editor of Zeitschrift für die gesamte Neurologie und Psychiatrie, founded by Alois Alzheimer and Max Lewandowsky in 1910. Most important, from 1924 to 1932, Foerster was president of the Gesellschaft deutscher Nervenärzte.

Foerster used his presidency of the Gesellschaft as a bully pulpit to promote the independence of the field. Each year he gave the opening addresses of the society’s annual meeting. As he asserted in his 1928 address, it was his “primary mission in life . . . to help our specialty, neurology, to independence [Selbständigkeit].”⁹⁵ He was clear on the most appropriate strategy. For Foerster, a neurologist should not only be well versed in the anatomy, physiology, and pathology of the nervous system, but also perform all diagnostic measures, such as encephalography and ventricular puncture. In the realm of the “overall therapy” the neurologist should “gain as much independence and autonomy as possible.” This included all surgical work on the nervous system, that is, operations on the spinal cords and peripheral nerves but also orthopedic and palliative interventions.⁹⁶

Foerster promoted this vision at other conferences, and most important at the First International Neurological Congress in 1931, in Bern. Here he authored a petition addressed to the state authorities of the participating nations to appeal for the independence of neurology, which was neglected in numerous countries and whose future was, “at least in [End Page 126] Germany, in serious danger.” Foerster’s proposal met with “enthusiastic applause [lebhafter Beifall].”⁹⁷

Foerster considered the congress an “important milestone on the path of neurology’s development,” especially because it bore witness to the breadth and importance of the specialty.⁹⁸ By that time, certain progress had been made toward independence, including the establishment of chairs of neurology at Hamburg, Breslau, Frankfurt, and Heidelberg. Nevertheless, to Foerster, these were only “partial successes”; neurologists in Germany were “still far away from the great final goal, the general recognition of neurology as a specialty [that is] equal to all other medical specialties.”⁹⁹

A great obstacle to institutional independence was the Great Depression. Apart from a few exceptions like Foerster’s own institute, there was little appetite for the establishment of independent neurological clinics and institutes to add to the already existing neuropsychiatric institutions. Political developments would make the goal of an independent neurology even more distant. Major neurologists including Kurt Goldstein had to leave Germany. In 1935, the Gesellschaft Deutscher Nervenärzte was shut down by the Nazis, who forcibly united it with the Deutsche Verein für Psychiatrie to create the Gesellschaft Deutscher Neurologen und Psychiater. In this way they consolidated the alliance with psychiatry that neurologists like Foerster had for decades tried to break. As the new president of the society and the Reichskommissar for the Deutsche Gesellschaft für Rassenhygiene Ernst Rüdin explained, the merger was due to the “fundamentally new attitude of the German State to the art of healing.” Because for the Nazis serious psychiatric and neurological diseases were [End Page 127] “hereditary [erblich bedingt],” it was clear that “prevention [was] better than cure.” To meet the new goals of the Nazi government, psychiatric and neurological concerns had to be united.¹⁰⁰ This dual renunciation of specialization and therapy must have been a slap in the face for Foerster, who henceforth attended the meetings of the internists.¹⁰¹

Foerster’s institute too suffered in the new conditions, despite Foerster’s attempt, in the words of Percival Bailey, to make “his peace with the Nazi government.”¹⁰² In his speech at the Wiesbaden congress for internal medicine in 1939, Foerster laid his neurology in the service of the Nazis. He suggested that the human organism showed itself to be the “truly perfected national socialist state,” a state in which members not only functioned by fulfilling their duties responding to orders from “the leading office [der führenden Stelle],” but “remain subservient” even “without contact with the Führung” because “national socialist ideas have become so deeply ingrained.”¹⁰³ He ended his paper with “Heil our Führer!”¹⁰⁴

Despite this gesture of loyalty to the Nazis, after the seizure of power, Foerster was in a precarious situation. His treatment of Lenin in the early 1920s made him an easy target, and his wife’s Jewish ancestry helped side-line [End Page 128] him in Nazi Germany. When Wilder Penfield revisited Breslau nine years after his first 1928 stay, he found a sick and old man, sitting alone in a “splendid Institute,” his assistants drafted to military matters, and his spirit broken.¹⁰⁵ The institute did not survive the war, and when Breslau became Polish again in 1945, the Wenzel-Hancke hospital and institute were handed over to the Akademia Ekonomiczna for the renamed University of Wrocław.¹⁰⁶

Foerster was unsuccessful then in establishing neurology as an independent specialty in the interwar period. But we should be wary of allowing that failure to overshadow what he had achieved. Providing a model for the future, in his own work and in his institute, and building the consensus and resolve for independence within the neurological community, he laid the groundwork for what was to come. When neurology emerged as an independent specialty in Germany in the 1960s, it built off and continued Foerster’s work.¹⁰⁷

Epilogue: Übungstherapie and the Paralympics

In working out the therapeutic dimensions of neurology, I have told a story of convergence, a meeting of sports and medicine. We have learned about the therapeutic appropriation of Turnen, the importance of Swedish forms of medical gymnastics and their integration into German medicine—at first in the context of the Kurort, then in hospital medicine—and the formation of a specifically neurological approach to gymnastics: Übungstherapie. While Frenkel applied Übungstherapie mostly in the treatment of tabes dorsalis, Foerster extended the therapeutic applications of the technique, integrating it into his neurosurgical practice. This transformation of Übungstherapie rendered its sports element almost unrecognizable. In Foerster’s version of Übungstherapie, exercise was largely medicalized, subsumed under a novel therapeutic regime. [End Page 129] However, after Foerster’s death, with the work of his assistant and later senior physician (Oberarzt), the Jewish émigré physician Ludwig Guttmann, sports entered the picture again.

Ludwig Guttmann (1899–1980) worked under Foerster from 1923 to 1933.¹⁰⁸ During that time, Guttmann published widely on the physiology and pathology of the spinal cord.¹⁰⁹ But after the Nazi rise to power, Guttmann first had to leave the Wenzel-Hancke hospital, and then flee Germany altogether.¹¹⁰ Nonetheless, even though new local influences began to shape Guttmann’s work when he made a new academic home in England, Foerster remained an important influence. Much in the spirit of Foerster’s work, Guttmann broke with the prevailing dogma that there was no treatment for patients with spinal cord injuries. He developed a program of occupational reintegration, which included the provision of adequate housing and adjusted work places, with the ultimate goal of putting men back to work. Most important, however, Guttmann emphasized the importance of bodily exercise in the treatment of his patients—a view that found fertile ground in the context of the gentlemanly sports culture and liberal economic tradition in Britain. He strongly believed in the beneficial physiological and social effects of physical activity in the treatment of nervous damage. He pointed out that the key to treating nervous damage lay less in “a specialized surgical technique” than in the “systematic after-treatment and after-care”: what he rendered in English as “rehabilitation.”¹¹¹

As head of the newly founded spinal cord unit at Stoke Mandeville Hospital in Aylesbury—he accepted the position in 1944, after having performed research on the spinal cord at Oxford for several years— Guttmann continued to emphasize the importance of bodily exercise for the treatment of patients with spinal cord injuries. From 1948 onward, he began to organize sporting events for the paralyzed on the hospital grounds. At first the games were a small and intimate affair: only two [End Page 130] teams competed, one from Stoke Mandeville, the other from the Star and Garter Home, a hospital for disabled ex-service personnel in Richmond. But in spirit, the games were modeled on a larger and grander sporting event taking place at the time less than fifty miles away: the fourteenth Olympic Games in London. In fact, despite differences in scale, the two events converged, and over time Guttmann’s “rehabilitation” games were transformed into an international competition, expanding en route to include the mentally ill and amputees. In organizing the First Paralympic Games—Rome, 1960—Ludwig Guttmann remained true to the belief in the therapeutic power of bodily exercise that had spurred the medicalization of gymnastics a half century before.¹¹² [End Page 131]