EMIL KRAEPELIN AND GERMAN PSYCHIATRY IN MULTICULTURAL DORPAT/TARTU, 1886-1891

Abstract

When the later famous psychiatrist Emil Kraepelin (1856-1926) was called to the University of Dorpat/Tartu at the age of 30, he probably did not busy himself much with the multicultural situation that he found there. Like many of his academic contemporaries, he regarded this Baltic university, then still German-speaking and one of the most important in the Russian Empire, as a kind of exile or at least only a way station for his career, which he hoped to pursue within the German Empire. He brought his research programme for the upcoming discipline of psychiatry with him, as the author of the compendium which, in the course of several editions, became a multi-volume, influential textbook. But at his new venue he found not only a complicated situation of (university) politics caught between negotiation processes among the various cultural groups, but also students from many regions and with different mother tongues, who had to adapt to the official language of instruction. In addition, he took over a recently founded university psychiatric clinic, where all parts of the population were represented, but with whom he could communicate only in a rudimentary manner, as far as the non-German-speaking population groups were concerned. But how did the patients from such different language families manage to make themselves heard in the world of university clinics headed by mostly German-speaking physicians, especially in psychiatry, a discipline particularly dependent upon language? What translation processes were performed by whom over the working therapeutic day, and what were the effects of this partial loss of speech on clinical research? What opportunities resulted from precisely this multi-lingual situation in a contact zone between Western Europe and Russia for psychiatric science and practice? This paper attempts to provide some preliminary answers to these questions, using already known and newly discovered sources.

Headnote

Abstract. When the later famous psychiatrist Emil Kraepelin (1856-1926) was called to the University of Dorpat/Tartu at the age of 30, he probably did not busy himself much with the multicultural situation that he found there. Like many of his academic contemporaries, he regarded this Baltic university, then still German-speaking and one of the most important in the Russian Empire, as a kind of exile or at least only a way station for his career, which he hoped to pursue within the German Empire. He brought his research programme for the upcoming discipline of psychiatry with him, as the author of the compendium which, in the course of several editions, became a multi-volume, influential textbook. But at his new venue he found not only a complicated situation of (university) politics caught between negotiation processes among the various cultural groups, but also students from many regions and with different mother tongues, who had to adapt to the official language of instruction. In addition, he took over a recently founded university psychiatric clinic, where all parts of the population were represented, but with whom he could communicate only in a rudimentary manner, as far as the non-German-speaking population groups were concerned. But how did the patients from such different language families manage to make themselves heard in the world of university clinics headed by mostly German-speaking physicians, especially in psychiatry, a discipline particularly dependent upon language? What translation processes were performed by whom over the working therapeutic day, and what were the effects of this partial loss of speech on clinical research? What opportunities resulted from precisely this multi-lingual situation in a contact zone between Western Europe and Russia for psychiatric science and practice? This paper attempts to provide some preliminary answers to these questions, using already known and newly discovered sources.

Keywords: Emil Kraepelin, history of psychiatry, multiculturalism, language, patient files, University of Dorpat/Jur'ev/Tartu, Germany, Russia

DOI: 10.3176/tr.2016.4.03

1. Languages in the psychiatric microcosm - Introduction

In her novel of 1955, dedicated 'to my home town of Dorpat', it seemed only right to the writer Else Hueck-Dehio (1897-1976), with her romanticising memories, that the figure of a Baltic German medical professor in Dorpat shortly before the First World War should be portrayed in a conversation with a patient speaking Estonian (Hueck-Dehio 1955:46-47). As the daughter of a well-known physician for internal medicine and pathology in Dorpat, Karl Dehio (1851-1927), who not only played an important role in the 'Medical Society of Dorpat' (EAA 3576.1.4, Meeting minutes of the Medical Society of Dorpat), but also at the University there since he was called in 1886, the author could well have obtained a view of medical practice in the city that she was to leave after the war. Her fictional figure, Professor Erhard Haller, understands the Estonian words of his patient, a peasant woman, who represents the native population and its demands. "I want him to be clever like you, Herr Professor", she says of her son, "and like all the many Saksad (Germans) living in their white houses, who understand everything better. The dear Lord did not create cleverness just for you. That is why we send our sons to the secondary school in the town". The professor in the novel, worried as he is about the future of the German-speaking elite and their culture in the Baltic region, still understands not only the words, but also the intention of the Estonian patient: "In his just heart he could not refuse the demand for social equality which the words of the peasant woman so clearly conveyed, the directness of it going straight to the heart, as does all that is primitive. He had been well acquainted with this phenomenon for years, namely the Estonian peasant sons who sat on the school benches, writing excellent examinations by means of iron-hard work. He saw here a development which not only could not be stopped, but was justified". Over 30 years after the rather abrupt end of Baltic German privilege in the Baltic provinces that had now long belonged to Russia, the author portrayed in a rather unreflective manner the elitist position of a professor towards the Estonian population, which was regarded as lower-class, but with whom he at least tried to communicate in their native language. But this was probably not a matter of course.

For a long time, the Medical Faculty in particular had been dominated by professors of the German Reich, who often saw their time in Dorpat as a temporary step on the career ladder and therefore paid little attention to the multicultural situation, and even less to the native language (Tammiksaar 2016). To learn Estonian - this was attempted only briefly even by the thirty-year-old psychiatrist Emil Kraepelin, who had been called to the university in 1886 from the German Empire to Dorpat. This foreign language seemed too difficult to him, and neither did he learn much of the official language, Russian. The academic language at the time at one of the leading universities of the northwestern part of the Russian Empire in the 19th century was, to a great extent, still German, a matter that, however, increasingly found refusal on the part of the Russian authorities responsible for education and universities, at the latest from the reign of Czar Alexander III (1881-1894). As is well-known, within a few years this was to change - the University of Dorpat was reorganised into the Russian University of Yur'ev in 1893, and Russian was established as the language of education in the course of the university reform (Donnert 2007:15, 29-69). The policy of enforced Russification caused difficulties particularly for the professors who came from the German Reich, but it also called up more or less open opposition among the Baltic Germans to the measures taken by the government in St. Petersburg (Donnert 2007:58-73). The language debate at the University of Dorpat expressed a general change of policy towards the Baltic regions on the part of the government in St. Petersburg, during which the autonomy of the University of Dorpat and other educational institutions in the Baltics was cancelled and non-Russian academics were replaced by Russian ones within a few years.

Kraepelin belonged to those who opposed Russification, as certainly did most German professors in Dorpat; this is documented, among other things, by his refusal to sign official documents in Russian (EAA. 402.3.865, Personnel file Kraepelin; Steinberg and Angermeyer 2001:302, Burgmair et al. 2003:37-38). There were only a few Russian professors in Dorpat at the time Kraepelin was called, a total of four out of a total of 46 (Steinberg and Angermeyer 2001:302), and in the Medical Faculty no one held a chair at this point in time (Donnert 2007: 176-198). The professors from the Baltic German elite also preferred the German language, although they were doubtless quite familiar with the official Russian, and to some extent with Estonian. Most students, in any case, were expected to show some linguistic flexibility, as the students came from many different countries; they did have to reckon with German as a language of instruction (Amburger 1987). But how did patients of the various language groups manage to make themselves heard in the world of university clinics mostly run by German-speaking doctors, especially in the psychiatric department, a discipline particularly dependent on language?

2. Clinical psychiatry in Dorpat

As was the case in Central Europe, modern psychiatry began to develop gradually in Russia during the second half of the 19th century. The first chair of psychiatry was established in 1859 at St. Petersburg Academy of Medicine and Science, followed by chairs in Moscow and Dorpat in 1880 (Donnert 2007:195, Steinberg and Angermeyer 2001:297). Beginning in the 1880s, the professionalization of Russian psychiatrists developed more dynamically (Zilboorg 1943, Vail Brown 1981, Sirotkina 2002, Steinberg 2008). Several independent psychiatric clinics were founded during this time, and the professional education of psychiatrists through the establishment of special academic institutions and professorships filled a serious deficit. The total number of psychiatrists in Russia, however, increased slowly at first (Zilboorg 1943:719). The Baltic area of the Russian Empire, historically shaped by German culture, housed its leading academic institution, the University of Dorpat, which was at that time one of the most renowned universities of the country and beyond in the field of medicine (Käbin 1986). Dorpat's Psychiatric Clinic was founded as a small private institution in 1877. With its opening in March 1877, eight women were admitted, for the entire period during which the small private clinic functioned, admission was offered only to female patients (Steinberg and Angermeyer 2001:298; EAA 402.5.930, letter of Emminghaus to the Direktorium, 22.8.1880). The first clinic was taken over by the State and the University in 1880 (Steinberg and Angermeyer 2001:298, Burgmair et al. 2003:25). In the same year, the decision was taken to build a new psychiatric hospital for 50 - male and female - patients. It was opened in April 1881 (Steinberg and Angermeyer 2001:298). Hermann Emminghaus (1845-1904), the first professor of the psychiatric university clinic, took over the chair for psychiatry even before this, in the summer of 1880, and left in the summer of 1886 to assume an appointment as professor in Freiburg (Steinberg and Angermeyer 2001:299). Kraepelin came as his successor in the summer of the same year. When he left for Heidelberg five years later, he was replaced by the Russian psychiatrist Vladimir F. Chizh (Ciz) (1855-1922). As one of the earliest stationary psychiatric institutions in the Russian Empire, the Dorpat clinic attracted people from a wide area, comprising Livland and Courland, too.

The psychiatric clinic had been newly built and finished by 1881, but soon problems with the inadequate building and finances commenced. One reason for this was that, apart from the professorial salary and that for two assistants, only 2,000 roubles were provided by the minor nobles - a sum which had to be negotiated anew every time - and the rest had to be covered by the nursing fees (Burgmair et al. 2003:26-27, Dehio 2003:302). While it is said of Emminghaus that his strength lay more in clinical and teaching activity, Kraepelin managed to become influential in financial administration and the re-design of the building as well, successfully retaining this influence to some extent even after he had left (Steinberg and Angermeyer 2001:299 and 313, Burgmair et al. 2003:28-29). Emminghaus soon had to struggle with another typical contemporary problem, overcrowding. His successors had the same difficulty (Steinberg and Angermeyer 2001:313). Only two years after the clinic had opened, Emminghaus wrote to the Board of Directors that the clinic could only keep its character of a place of recovery and teaching if 'measures are taken in time to remove over-aged and incurable cases of mental derangement'. For teaching purposes, patients freshly taken ill were needed (EAA 402.5.930, letter of Emminghaus to the Direktorium, 12.10.1883). In a similar vein, Kraepelin pointed out six years later 'the monotony of demonstration teaching', which could only be 'finally eliminated through a complete reform of psychiatric care in the country', in his opinion (EAA 402.5.930, letter of Kraepelin to the Direktorium, 16.5.1889).

The teaching activity with 'psychiatric demonstrations' took place for the most part in a dining room of the clinic, which had opened in 1881, probably even before nursing care there began, with patients from the previous small institution (EAA 402.5.930, letter of Emminghaus to the Direktorium, 22.8.1880). Kraepelin later obtained a room, rented in town, which was more accessible for the students. Kraepelin delivered a lecture on 'clinical psychiatry' each semester during his time in Dorpat. In any case, he apparently did his best to deliver interesting lectures at Dorpat, presenting patients, and that he succeeded in doing so - students travelled long distances to attend them (Burgmair et al. 2003:31-33, Dehio 2003:304). It is not clear, however, whether he presented only German-speaking patients.

Kraepelin reported in his memoirs that the number of attendees amounted to about 50, and consisted of different groups. The majority was made up of 'actual Balts', and the rest were Polish and Jewish students, the latter coming from both Poland and Russia (Kraepelin 1983:47-48). Official university statistics show that in the years 1882-1886, of the 1,578 students at the University of Dorpat, 523 came from different parts of the Russian state, not including the Baltic region of the Empire. Among the students, 552 were Livonians, 335 came from Courland, 145 from Estonia, and 23 were 'foreigners' (Steinberg and Angermeyer 2001: 302). Approximately two-thirds of the students thus came from the Baltic provinces of the Russian Empire, in other words, the three Baltic governorates of the time, Estonia, Livland and Courland. Their borders did not always correspond to the linguistic borders (for instance, the southern part of the Estonian language area, in which Dorpat, too, was located, belonged to the Governorate of Livland). Those students who came from the Governorate of Courland and the more southerly areas of Livland will have made themselves understood in German and Russian; it was unlikely that they were able to make themselves understood by the native population.

The composition of the student body was - at least in part - reflected in that of the assistants of the psychiatric clinic. From 1881 until the end of 1892, there was the director, then two assistants, the number being increased thereafter to three. In the first semester, in 1886, directly prior to Kraepelin's arrival, the two positions were occupied by Hermann Graff from Livland and August Sohrt (born 1862) from St. Petersburg. In the second semester, August Sohrt was still there, and thus became Kraepelin's first assistant. Before this, Sohrt had defended in 1885 his dissertation on the psychopharmacological effect of hyoscine, seen as one of the first clinical studies on psychopharmaceuticals (Steinberg and Angermeyer 2001: 304-305 and 321 n 62). Sohrt, the son of an Imperial Russian court gardener, received his schooling at a Russian school in Tsarskoye Selo (EAA.402.2.23546, Personnel file of student August Sohrt and EAA. 402.2.23545, Personnel file containing diverse documents including the enrolment at Dorpat University), but was from a German family - his father, August Heinrich Sohrt had immigrated to Russia - and thus perhaps chose Dorpat in 1880 because of the language issue.

In the summer of 1886, shortly before Kraepelin arrived, Heinrich Dehio (1861-1928), a cousin of Professor Karl Dehio, came to Dorpat and stayed until the end of 1889. Dehio reported in his memoirs that he was able to greet Kraepelin on the latter's arrival as his head of department, and that he owed Kraepelin 'the most important part of (my) psychiatric training' (Dehio 2003:301). In the summer of 1887, Eduard Michelson, also from Estonia, replaced Sohrt, who had returned to St. Petersburg; Michelson remained until mid-1892, thus remaining when Kraepelin's successor had taken over the direction of the clinic in the second semester of 1891. This was true, too, of Leon Daraszkievicz (1866-post-1926) from Courland, one of Kraepelin's doctoral students in Dorpat, who replaced Heinrich Dehio in the clinic in 1890. After the Russian psychiatrist Vladimir F. Chizh had taken over the clinic, he evidently did not immediately change the employment policy, for after Michelson had left in 1892, he employed Ernst Sokolowski from Livland as the new assistant. It is possible that the employment policy was intended to help with the problem of communication with the natives, something that was equally difficult for the German professors Emminghaus and Kraepelin on the one hand, and for the Russian Chizh on the other. Thus, Heinrich Dehio reports in his memoirs of Kraepelin's time in Dorpat that the assistant physicians also had the job of translation, which, according to what Dehio says, was starkly limited in a linguistic sense: "Dealing with patients from the lowest classes was difficult for Kraepelin, as these people understood only the languages of the country, Estonian and Latvian, while we assistants had only the vaguest idea of these languages, so that our translation and interpreting activities did not go far" (Dehio 2003:303). Apart from the physicians, members of other professions also worked in the clinic, which according to Dehio was designed for about 56 patients, but was generally occupied by nearly 100 patients in three nursing categories (Dehio 2003:302-203). The other people working at the clinic, the warders, the housekeepers, gardeners, coach drivers and machinists, belonged to different groups in the population and could thus have performed an important role in daily communication. Their names point to mainly German and Estonian origins; among the warders, Estonian names dominate (Steinberg and Angermeyer 2001: 312-313).

3. Psychiatric science without language?

Kraepelin, at any rate, said later that he was disappointed at having been hardly able to speak with his patients in Dorpat, and he regarded this circumstance as a hindrance to his research. In his memory, it was only in Heidelberg that 'more favourable conditions than ever before' came along in his clinical research (Kraepelin 1883:III, Burgmair et al. 2003:49). It was probably at Heidelberg that Kraepelin began to work with the famous scorecards (Engstrom 2005:233, see also Roelcke 2003:171). In his memoirs Kraepelin ascribed a low quality to his clinical research of the Dorpat period. For example, he stated with regard to the Dorpat editions of his textbook: "Owing to the unfavourable conditions under which my clinical activity was exercised, I was only able to stay on the well-beaten track without making any particular progress" (Kraepelin 1983:49).

No such statement by Emminghaus is known about the negative effect of a patient speaking a foreign language on attempts at psychiatric classification. But the question of linguistic contact with patients in his attempts at clinical classifica- tion must have been equally relevant. In 1887, shortly after returning from Dorpat, Emminghaus published his textbook on child psychiatry, which can be seen as one of the founding texts for the psychiatry of minors and which is based at least partly on clinical experience in Dorpat (Steinberg and Angermeyer 2001:299).

Since Kraepelin could not understand some of his patients without an interpreter, as stated by Steinberg and Angermeyer, perhaps it seemed easier to adopt a non-verbal experimental approach (Hoff 1994, Steinberg and Angermeyer 2001: 308, Burgmair et al. 2003:49). In this interpretation, the language situation could have been one reason for the main research focus of Kraepelin at Dorpat on experimental psychology, on the themes and methods of his teacher Wilhelm Wundt (Burgmair et al 2003:41, 45-48). But while the experimental approach was certainly predominant in Kraepelin?s work at Dorpat (Burgmair et al. 2003:49-53), he also took a decisive turn towards nosology during his time there (Steinberg and Angermeyer 2001:308-310). Kraepelin himself stated in his memoirs that it was during those years that ?the ever-increasing conviction of the importance of the development of the disease for the classification of insanity? imposed itself on his thinking (Kraepelin 1983:49). Could that really be possible without personal dialogue with the patients, apart from a little with the help of an interpreter, and otherwise only on the basis of non-verbal symptoms? And in that case, what could these mute signs of ?madness? have been? It is certainly true that observation must concentrate more on non-linguistic tasks if verbal exchange is not possible, on mimicry and gestures, on the behaviour observed.

But this must have corresponded more to Kraepelin?s tendencies in his Dorpat period in any case; he placed quantifiable symptoms, whose cognitive content was independent of speech, more in the foreground as against the psychological dimension and thus to emphasise the scientific foundations of psychiatry (Roelcke 1999, Roelcke 2003:186). Perhaps Dehio?s evaluation in his memoirs is to be interpreted in this direction, when he says that the ?patient material? was not large in volume, and language difficulties made dealing with the patients more difficult, despite the assistant physicians translating activities, but that ?the observation of every single case was all the more thorough? - ?and that this was not in vain, is proven by the scientific results of the Dorpat years?. Kraepelin himself is supposed to have expressed his incomprehension of German clinicians complaining that they had ?too little patient material?, saying that he himself had ?enough to do with his few patients and sufficient material for clinical presentations? (later, in Heidelberg, as is known, he was to join in the chorus of complaints about a lack of fresh patients with manifold clinical presentations for teaching and research, and even demand that the conditions of admission, and thus of this circumstance, should be altered, as a condition for his remaining in Heidelberg, but in vain). Dehio adds that his teacher in the Dorpat years was ?a seeker of new and certain paths in clinical research?, who was able to draw in his only slightly younger assistants into his world of thought by means of the suggestive power of his personality (Dehio 2003:303). At the time he wrote his memoirs, after Kraepelin?s death in 1926, Dehio knew, of course, that the nosologist had become famous through clinical research; he may have had an interest in ensuring that this research, seen as significant for the development of the entire discipline, was known to have been conducted in Dorpat, too.

But it is true that Kraepelin engaged in clinical research and experimental psychology from the very beginning of his career in Dorpat, while contemporary brain anatomy, greatly valued by contemporaries, was never something he represented programmatically, nor did he use it in practice. Already in 1886, in his inaugural lecture, the audience heard his opinion that progress in psychiatry depends on the combination of the two research fields named, experimental psychology and clinical psychiatry (Steinberg and Angermeyer 2001:302). This is not surprising, given that three years before being called to the chair in Dorpat, he had made clear in his compendium of 1883 that he regarded experimental psychology as an ancillary to clinical psychopathology. The strictly 'scientific' procedures of psychological experiments might, in Kraepelin's view, effect the necessary establishment of clinical psychopathology within the scientific paradigm, and thus also effect the desired systematization (Roelcke 2003:182-185; see in contrast Steinberg and Angermeyer 2001:322 n. 89). Besides the pursuit of a clinical symptomatology based on experimentally determined 'single functions' (Kraepelin 2003:74), the experiments may have been an inspiration for Kraepelin's later emphasis on the observation of courses of diseases, as these experiments also involved the dimension of time (Burgmair et al. 2003:52-53).

At a key moment, at the end of his inaugural lecture, Kraepelin spoke about classification as a significant task for the psychiatrist, despite all the understandable resignation concerning the then current state of knowledge about nosology (Kraepelin 2003:75, see also Roelcke 2003:182). He did not yet emphasize the importance of the courses or development of these disease entities as strongly as he did in later writings. However, he did mention Karl Ludwig Kahlbaum (18281899) as a model for psychiatric research; as Kahlbaum was probably unknown to most of the audience, nobody present could know that Kahlbaum had insisted on observing the course and trends in analysing catatonic conditions (Kraepelin 2003: 76. See also Steinberg and Angermeyer 2001:307, Burgmair et al. 2003:53). In the second edition of the textbook, too, Kahlbaum's idea of observing the course played a greater role than in the compendium. In his memoirs, Dehio notes that in the third edition of the textbook, written in Dorpat, Kraepelin emphasised the course of the psychoses in describing the 'catatonic madness', and so shown 'in which direction Kraepelin's clinical thinking was now going' (Dehio 2003:310). The fourth edition is seen as a witness of the development of an independent nosology, and, as this edition appeared in 1893, some of the Dorpat clinical experiences must have found their way into it (Steinberg and Angermeyer 2001: 307).

Kraepelin actually admitted in his inaugural lecture that 'a way out of the labyrinth of clinical pictures cannot be seen for the moment'. But the objective was to be reached by means of the classification of 'mental disorder symptoms' based on sober observation, a monographic treatment of 'all those little variations and intermediate forms, which today, well-known to the individual practitioner, are brought together indiscriminately in the oversized categories of popular nomenclature, which are therefore devoid of meaning' (Kraepelin 2003:76-77). Only afterwards would it be possible to delimit each of the clinical pictures at a higher level, and ascribe them in a final step to their pathological causes.

Both of Kraepelin's main scientific topics that were programmatically linked to each other were also reflected in the nine doctoral theses he supervised during his Dorpat period. Seven dealt only with experimental psychology, two were dedicated to clinical subjects: catatonia (Albert Behr, 1860-1919) and hebephrenia (Leon Daraszkiewicz, 1866-post-1926), both of which were important for Kraepelin's later conception of dementia praecox (Dehio 2003:309, Burgmair et al. 2003:42).

Ever since the first edition of his textbook, Kraepelin, in his description of clinical pictures, had tended towards extensive juxtapositions, and thus the formation of types. He gave an example of 'melancholy with delusions': "The patient is afraid of becoming seriously ill, of being impoverished; therefore, he has no money to pay for food and suddenly believes that something terrible has happened to his wife, his children, that his house was burnt down, that the apocalypse is imminent and similar occurrences" (Kraepelin 1883:204). He continually referred to 'the patient', 'the person who is ill', meaning the typical patient, not a specific individual. Although Kraepelin had already worked in psychiatry as an assistant physician, he only appears to have described concrete, personal observations during his stay in Dorpat: "Then I saw a young melancholic bursting into bitter tears while listening to merry music" (Kraepelin 1889:284). One could doubt that Kraepelin's time in Dorpat coincided with the beginnings of psychiatric concept formation, because he had already developed the nucleus of his scientific programme before this. But at Dorpat a phase began in which, above all, the accuracy of clinical observation was increasingly reflected in the textbook (Wübben 2012: 84-89). He recalls later in his memoirs that it was only in the last years of his stay in Dorpat that he was able to determine 'more clearly the more or less rapid forms of mental enfeeblement from the incoming cases' (Kraepelin 1983:49).

4. The Dorpat Clinic and its patients - new findings from patient files

Before patients can be used as 'cases' for a textbook, medical notes recorded in case histories document their statements, as well as the 'symptoms' and behaviours observed. These sources, which are essentially written for the use of medical colleagues, usually explain little, relying on the reader to draw the conclusions intended by the author from the written observations. While diagnostic considerations are rare, case histories have been used as an auxiliary tool for nosological classification (Wübben 2012:89-103, Rotzoll 2013). It is doubtful, however, that the actual construction of disease entities can be identified in the files. Nonetheless, the experiences of the patients, including their regional, historical, and cultural backgrounds, found their way into books and scientific tradition. Since Kraepelin had the opportunity, for the first time, to observe patients and the courses of their illnesses for longer periods of time during his stay in Dorpat, it can rightly be inferred that Dorpat's patients had an impact on the development of his classification system, perhaps even more decisively than his later patients at Heidelberg and Munich.

Hitherto very little was known of the patients of the one-time Dorpat Psychiatric Clinic, apart from minor mentions, such as the picture of a melancholic girl from Estonia in Emminghaus' textbook, or the mention of an Estonian peasant in the various editions of Kraepelin's textbook. Chizh and Michelson, however, published a report on the first ten years of the Dorpat clinic, in which they included statistical information on the ethnic status of the patients. According to this, during the period mentioned 50% of the patients were Estonian, generally from the rural areas, 30% German, 8% from Livland, 3% Jewish, and 2% Russian (this list suggests that patients were not registered according to nationality or region, but rather according to language spoken and, where necessary, religion - in principle, they all were subjects of the Russian Empire and many of those classified as 'Estonian' will have lived near Dorpat, which was part of Livland). The authors themselves doubted the validity of their results, as they suspected that too many patients had claimed to be German for prestige reasons (Steinberg and Angermeyer 2001:320). The exact composition of the patient population remained uncertain, just as it was unclear, exactly which languages were reflected in the patient files.

Until recent research, it was not clear whether some of the Dorpat files from Kraepelin's time had been preserved. The German psychiatrist Kurt Schneider (1887-1967), one of Kraepelin's successors at Heidelberg, seems to have consulted some files written by Kraepelin during World War II. According to Holger Steinberg and Matthias Angermeyer, "many of them can still be found in the Estonian National Archives" (Steinberg and Angermeyer 2001:318). Wolfgang Burgmair, Eric J. Engstrom, Albrecht Hirschmüller, and Matthias M. Weber, in their book "Kraepelin in Dorpat", did not mention any possibly preserved patient files (Burgmair et al. 2003), and neither did Florian Mildenberger in a 2011 publication (Mildenberger 2011). Yvonne Wübben assumed that the patient files from the Kraepelin era are probably lost (Wübben 2012:89). These authors, if they were interested in patient files, seem to have concentrated their research on the Estonian National Archives, where other documentation of Dorpat University and its psychiatric clinic is preserved. In 2007, Ken Kalling did publish on the fate of Estonian psychiatric patients during the Second World War. During his research, he used patient files preserved in the archives of the psychiatric clinic (Kalling 2007). So, with the friendly help of Ken Kalling and Erki Tammiksaar, it was possible to trace the files from Emminghaus' and Kraepelin's times in the archives of the psychiatric clinic at Tartu - the files preserved there date almost from the foundation of the clinic onwards. This finding can also be used to resolve the question of which languages were relevant for Kraepelin's patients.

The files are organised chronologically, according to admission date; the numbers originally given do not, however, all have a corresponding file. There is no admissions or discharge register. The files begin with N° 2, that of the patient Emilie J. She was admitted on 9 August 1878, when the clinic was still a private institution. She remained in the clinic for several years, evidently being taken along as a patient when the clinic moved to the new building, and died in 1895. No diagnosis was made. This is the only patient file surviving from the time before the clinic became a University clinic. This suggests that the private clinic, founded in 1877, did not have patient files, or had another system of patient files, not preserved, so that this file was probably created when Emilie J. (and two other patients with the files 1 and 3, both lost) became a patient of the new University clinic. The next file, N° 4, was created for Leena L., who was admitted on 1 January 1881 and discharged on 21 December 1883. Here we find the diagnosis 'Mania' noted on the file cover. At the time of her admission, Emminghaus was already in Dorpat, but the clinic had not yet moved into the new building (this did not occur until April 1881). The first files, then, were all created for women, and admissions were rare. File N° 11, for Kristine K., is the first file to date from after the move. From this point onward, files exist for male patients, too. The files are kept in stacks in the archives of the psychiatric clinic in Tartu, each stack consisting of 100 numbers (from 1-99, 100-199, and so on). If each number actually represents a file, then around 800 patients must have been admitted during Kraepelin's tenure, about 140 annually on average. Approximately 60% of these files is still in existence, without any systematic reason for the one or the other missing file being visible. The collection also covers the period after Kraepelin, but now there is an increasing number of Russian forms and records (as far as can be established by random sampling).

It is known that Emminghaus had already ordered the careful upkeep of psychiatric patient files (Steinberg and Angermeyer 2001:298-299). This fits in with his relatively rapid introduction of a standard questionnaire in which the criteria that he felt most important were noted. Interestingly, these questionnaires, which were later used by Kraepelin without change, were bilingual, one-half of the double page being in one language, the other half in the other. The first example of this questionnaire is found in File N° 53, for Marri W., who was admitted on 24 October 1881 with the diagnosis of 'religious confusion' (and after this the questionnaire is found in most files).

Although the patient was an Estonian woman, only the name and address of her father were noted on the Estonian part of the questionnaire; all other information was written down in the German part. That the information was provided from her husband was also noted. One may, then, assume in this case two 'processes of translation' - the information was not provided by the patient herself, and it was noted down in the main language of the person handling the file, probably an assistant physician or maybe the committing physician. That the questionnaire had been designed for the Dorpat clinic is clear from its heading, "Questionnaire for Admittance to the Psychiatric Clinic in Dorpat". It was possibly designed to use also for physicians not working in the clinic itself, as suggested by the note on the questionnaire saying, "It is advisable when transferring a patient to the clinic not to use any tricks, but to tell the patient that he is in need of institutional treatment now". The questions are only partly about simple personal details: name, age, place of residence, address, representative, parents and siblings. For the questions about 'original mental state', earlier illnesses, and lifestyle, there must have been a more thorough conversation with the patient or his or her relatives. This is even more the case with questions about alleged physical and mental causes of illness, the course and the symptoms, treatment so far, and the reason for being admitted. For Marri W., for example, 'horror' about the death of her five-week-old child was given as the mental cause; the reason for admittance was a worsening of her condition over a period of weeks. As is the case with most of the files, this one includes an anamnesis in addition to the questionnaire, physical findings entitled 'status praesens', a few pages of notes on the course of the illness, a weight curve, and finally a first-person document, a one-page text written in Estonian and signed by the patient. Many files contain in addition official documents in various languages, some translated.

The extent of the files varies considerably; some have only a few pages, some over 100 - in the latter cases, the patients are usually from the German-speaking upper classes, who should probably be seen as the upper class when it came to nursing as well. Their relatives frequently wrote to ask how their ill relatives were doing. In such files, especially, we find the answers by head physicians or assistant physicians, or probably their concepts. Thus, in some files we find short pieces of writing by Kraepelin, as far as relatives or medical colleagues had written to him in German.

These are generally short notes, as in the file of the Estonian patient Jahn W., N° 430, who was treated in the clinic for epilepsy in 1885, and concerning whose illness an inquiry came in 1890. In this case, Kraepelin simply noted briefly on 3 March 1890, 'impossible to answer the questions on the basis of the material available here'. In the files of patients from the German upper classes, the answers are to some extent somewhat more detailed, thus in File N° 589 for the patient Adda von St., or in File N° 687 for Paul von B., which contains much correspondence with Kraepelin, Michelson, und Dehio. On the average, the files of the German-speaking patients are more substantial and revealing; this may be because of their social status as much as the linguistic circumstances.

A preliminary analysis of the patient files for the year 1886, when Kraepelin replaced Emminghaus, shows that during this period 117 patients must have been admitted, whose files are numbered from 446 to 652. Not all of these have been found hitherto in the collection; some 70 are present. 40 files record the admission of men, 30 of women. The majority of last names (37) points to German speakers, while 30 files have Estonian-sounding names and three have Russian-sounding names. Four female patients with noble last names point to the fact that all social levels were represented in the three-tier psychiatric system. During this year, when the change from Emminghaus to Kraepelin occurred, frequent diagnoses are paranoia (9), melancholy (9), mania (8), Dementia secondaria (8), Dementia paralytica (7), imbecility (5), alcoholism (5) and depressive madness (5). A more exact investigation of the archives would show whether any change in categories and any transfers in numbers took place in the subsequent years. A future examination would also reveal how the different languages of patients and psychiatrists, connected frequently with differing social positions, had an effect on the psychiatric recording system in Dorpat and its content. Certainly, translation processes would appear on different levels, not least the 'transfer' from the files to the textbooks, which then became part of an international reception.

5. Processes of translation and exchange: Kraepelin's classifications as part of a science dialogue between Germany and Russia in the area of psychiatry

The city of Dorpat (Estonian Tartu), located in the Baltics at the crossroads of East and West, had constituted a contact zone between Estonians, Livonians, Balts, Russians, Germans and other peoples since the Middle Ages. Political and cultural dominance over the city was highly contested and changed several times over the centuries. During the 19th and early 20th centuries, the area of science and the academic life of Dorpat were mainly shaped by German and Russian cultures. As the only German-language university in the Russian Empire, the University of Dorpat represented a particular interface and 'transit space' for all kinds of academic and expert knowledge between Germany and Russia. The period from the 1880s until the early 1900s in particular was characterized by intensive cross-cultural encounters and processes of exchange in the fields of medicine and science between the two nations.

The phenomenon of German-Russian encounters and mutual interaction in the field of psychiatry can be well demonstrated using the example of Emil Kraeplin's scholarly activities and his scientific works, mainly evolved or written during his time in Dorpat or in the subsequent years. In fact, Kraepelin's experience at the University of Dorpat had a definite impact on Russian psychiatry in different ways. First of all, Kraepelin took the teaching of future physicians very seriously, being well aware that they would spread their newly acquired knowledge throughout many parts of the Russian Empire. Kraepelin recognized his own role in this process. A former student reported that in the process of the professor rigorously examining students aspiring to become psychiatrists, they became real specialists in that respective area (Steinberg and Angermeyer 2001:315).

Moreover, Kraepelin's first short textbook on psychiatry, the Compendium der Psychiatrie, first published in German in 1883 (Kraepelin 1883), was translated into Russian as early as 1891 (Kraepelin 1891). This year marked also the end of his stay as a professor of psychiatry at the University of Dorpat. Further works by Kraepelin and new editions of his textbooks on psychiatry were translated into Russian from the late 1890s onwards. His works were also regularly reviewed in leading medical journals in Russia, such as the "Korsakov Journal of Neuropathology and Psychiatry" (See, e.g., Bernstejn 1901, Bernstejn 1902).

As other leading psychiatrists from Europe, in particular from France and Germany, during the 19th and early 20th centuries, Kraepelin was met with considerable interest among Russian psychiatrists. Above all, it was Kraepelin's approach towards nosological psychiatry which evoked substantial interest among Russian experts. However, also in Russia different attempts had been made to establish a classification of mental disorders, reaching back to the 1840s. In this context, we would like to mention here only the efforts by the leading Russian psychiatrists Justin E. Djad'kovskij (1784-1841) and Sergej S. Korsakov (18541900). In particular Korsakov, the founder of the Moscow psychiatric school, became famous in Russia for supporting the nosological approach in the understanding and systematization of psychiatric illnesses (Ovsyannikov and Ovsyannikov 2007).

It is perfectly conceivable that Kraepelin was facing different classifications of mental illnesses by Russian psychiatrists during his stay at the University of Dorpat. According to a famous Soviet textbook of psychiatry, Kraepelin did make use of the earlier classification by Korsakov (Slucevskij 1957:29). Korsakov, who was personally acquainted with a number of leading European psychiatrists, among them Paul Flechsig (1847-1929) in Leipzig, Richard von Krafft-Ebing (1840-1902) in Vienna, and Jacques Joseph Valentin Magnan (1835-1916) in Paris, met with his German colleague Kraepelin in 1894 in Heidelberg, but we can safely assume that both had been familiar with the works of the other for some years already. At the beginning of the 20th century, however, in Russian psychiatry, there was still a dissatisfaction with the existing propositions of classifications of mental diseases, which was a major reason for the keen interest in Kraepelin's new approach to nosology (Slucevskij 1957:29).

However, while not denying the central role of Kraepelin's nosological research in Russia, of course, it would be nevertheless one-sided to speak only of a 'classic' transfer of medical knowledge from West to East, from Europe to Russia, travelling in only one direction. In fact, the most important research Russian scientists received from Germany was critically discussed, modified, and filtered through their own background and clinical research. This was, for example, the case with Sergej A. Suxanov's (1867-1915) partial criticism of Kraepelin's momentous redefinition of the term melancholy and its reduced understanding as a mainly age-related melancholy, which was presented by the German psychiatrist in the fifth edition (1896) of his famous textbook on psychiatry (Kraepelin 1896). Only afterwards, between the seventh (1903/4) and the eighth (1909/1913) editions, did Kraepelin decide - due to the criticism of his contemporaries, including the Russian psychiatrist Suxanov (Suxanov and Gannuskin 1902, Suxanov 1906) - to eliminate the notion of melancholy as related to old age or to integrate it into manic-depressive insanity. It appears more appropriate, therefore, to view the production and movement of concepts of melancholy in Western Europe and Russia around 1900 in the context of the medicalization of melancholy as an aspect of the circulation of knowledge. The multicultural city of Dorpat with its leading university played a central role in these processes of generation and circulation of medical knowledge between the West and East, as the example of Emil Kraepelin's nosological research shows.

References

References

Amburger, Erik (1987) "Die Bedeutung der Universität Dorpat für Osteuropa. Untersucht an der Zusammensetzung des Lehrkörpers und der Studentenschaft in den Jahren 1802-1889." In Gert von Pistohlkors, Toivo U. Raun, and Paul Kaegbein, eds. Die Universitäten Dorpat/ Tartu, Riga und Wilna/Vilnius 1579-1979: Beiträge zu ihrer Geschichte und ihrer Wirkung im Grenzbereich zwischen Ost und West, 163-182. Köln, Wien: Böhlau.

Anonym (1882-1887 and 1888-1895) Personal der Kaiserlichen Universität zu Dorpat, gedruckt auf Verfügung der Universitätsverwaltung, Druck von Schnakenburg's Buchdruckerei. [From 1892 onwards in Russian language].

Bernstejn, Aleksandr Nikolaevic (1901) "Emil Kräpelin. Einführung in die Psychiatrische Klinik. Dreissig Vorlesungen. Leipzig: J. A. Barth, 1901" (review). In Zumal nevropatologii i psixiatrii imeni S. S. Korsakova 1, 2, 487-489.

Bernstejn, Aleksandr Nikolaevic (1902) "Prof. E. Kräpelin. Vvedenie v psixiatriceskuju kliniku. 30 kliniceskix lekcii. Pereveli s nemeckago vraci Ja. F. Kaplan i S. A. Kaplan. Ufa 1901." Zurnal nevropatologii i psixiatrii imeni S. S. Korsakova 2, 5, 1104-1105.

Burgmair, Wolfgang et al. (2003) "Die Dorpater Klinik ist keineswegs schlecht." In Wolfgang Burgmair, Eric J. Engstrom, Albrecht Hirschmüller, and Matthias M. Weber, eds. Kraepelin in Dorpat 1886-1891, 17-53. München: Belleville.

Dehio, Heinrich (2003) "Meine Erinnerungen an Professor E. Kraepelin in Dorpat u. Heidelberg." In Wolfgang Burgmair, Eric J. Engstrom, Albrecht Hirschmüller, and Matthias M. Weber, eds. Kraepelin in Dorpat 1886-1891, 301-323. München: Belleville,

Donnert, Erich (2007) Die Universität Dorpat-Jur'ev 1802-1918: Ein Beitrag zur Geschichte des Hochschulwesens in den Ostseeprovinzen des Russischen Reiches. Frankfurt a.M. [et al.]: Lang.

Emminghaus, Hermann (1987) Die psychischen Störungen des Kindesalters. Tübingen: Verlag der Laupp'schen Buchhandlung.

Engstrom, Eric J. (2005) "Ökonomie klinischer Inskription: Zu diagnostischen und nosologischen Schreibpraktiken in der Psychiatrie." In Cornelius Borck and Armin Schäfer, eds. Psychographien, 219-240. Zürich: Diaphenes.

Engstrom, Eric and Kenneth S. Kendler (2015) "Emil Kraepelin: Icon and Reality". American Journal of Psychiatry 172, 12, 1190-1196.

Hoff, Paul (1994) Emil Kraepelin und die Psychiatrie als klinische Wissenschaft. Ein Beitrag zum Selbstverständnis psychiatrischer Forschung. (Monographien aus dem Gesamtgebiete der Psychiatrie, 73.) Berlin et al.: Springer.

Hueck-Dehio, Else (1955) Liebe Renata. Geschichte einer Jugend. Heilbronn, Egon Salzer Verlag.

Käbin, Ilo (1986) Die medizinische Forschung und Lehre an der Universität Dorpat/Tartu 1802-1940. Ergebnisse und Bedeutung für die Entwicklung der Medizin. Lüneburg: Verlag Nordostdt. Kulturwerk.

Kalling, Ken (2007) "Estonian psychiatric hospitals during the German occupation (1941-1944)." International Journal of Mental Health 36, 89-98.

Kraepelin, Emil (1883) Compendium der Psychiatrie. Zum Gebrauch für Studierende und Ärzte. Leipzig: Abel Verlag.

Kraepelin, Emil (1889) Psychiatrie. Ein kurzes Lehrbuch für Studierende und Ärzte. 3rd ed. Leipzig: Abel Verlag.

Kraepelin, Emil (1891) Kratkoe rukovodstvo po psixiatrii dlja vracej i studentov. Sankt Peterburg: Prakticeskaja medicina.

Kraepelin, Emil (1893) Psychiatrie. Ein kurzes Lehrbuch für Studierende und Ärzte. 4th ed. Leipzig: Abel Verlag.

Kraepelin, Emil (1896) Psychiatrie. Ein Lehrbuch für Studierende und Ärzte. 5th ed. Leipzig: Ambrosius Barth.

Kraepelin, Emil (1899) Psychiatrie. Ein Lehrbuch für Studierende und Ärzte, 2 Vol. 6th ed. Leipzig: Ambrosius Barth.

Kraepelin, Emil (1901) Einführung in die Psychiatrische Klinik. Zweiunddreißig Vorlesungen. Leipzig: Ambrosius Barth.

Kraepelin, Emil (1903/1904) Psychiatrie. Ein Lehrbuch für Studierende und Ärzte, 2 Vol. 7th ed. Leipzig: Ambrosius Barth.

Kraepelin, Emil (1905) Einführung in die Psychiatrische Klinik. Zweiunddreißig Vorlesungen. 2nd ed. Leipzig: Ambrosius Barth.

Kraepelin, Emil (1909/1913) Psychiatrie. Ein Lehrbuch für Studierende und Ärzte, 2 Vol. 8th ed. Leipzig: Ambrosius Barth.

Kraepelin, Emil (1921) Einführung in die Psychiatrische Klinik. Zweiunddreißig Vorlesungen. Kraepelin, Emil. Einführung in die Psychiatrische Klinik. Zweiunddreißig Vorlesungen. 4th ed. Leipzig: Ambrosius Barth.

Kraepelin, Emil (1983) Lebenserinnerungen. Berlin, Heidelberg, New York, and Tokyo: Springer.

Kraepelin, Emil (2003) "Die Richtungen der Psychiatrischen Forschung." In Wolfgang Burgmair, Eric J. Engstrom, Albrecht Hirschmüller, and Matthias M. Weber, eds. Kraepelin in Dorpat 1886-1891, 55-78. München: Belleville.

Mildenberger, Florian (2011) "Emil Kraepelin (1856-1926) in Dorpat. Psychiatriereform im panslawistischen Daseinskampf." In Ortrun Riha and Marta Fischer, eds. Naturwissenschaft als Kommunikationsraum zwischen Deutschland und Russland im 19. Jahrhundert, 219-232. (Relationes, 6.) Aachen: Shaker-Verlag.

Ovsyannikov, S. A. and A. S. Ovsyannikov. "Sergey S. Korsakov and the beginning of Russian psychiatry." Journal of the History of the Neurosciences 16, 1-2, 58-64.

Roelcke, Volker (1999) "Laborwissenschaft und Psychiatrie: Prämissen und Implikationen bei Emil Kraepelins Neuformulierung der psychiatrischen Krankheitslehre." In Christoph Gradmann and Thomas Schlich, eds. Strategien der Kausalität. Konzepte der Krankheitsverursachung im 19. Und 20. Jahrhundert, 93-116. Pfaffenwerder: Centaurus.

Roelcke, Volker (2003) "Unterwegs zur Psychiatrie als Wissenschaft: Das Projekt einer 'Irrenstatistik' und Emil Kraepelins Neuformulierung der psychiatrischen Klassifikation." In Eric. J. Engstrom and Volker Roelcke, eds. Psychiatrie im 19. Jahrhundert. Forschungen zur Geschichte von Psychiatrischen Institutionen, Debatten und Praktiken im deutschen Sprachraum, 169-188. (Medizinische Forschung, 13.) Basel: Schwabe-Verlag.

Rotzoll, Maike (2013) "Krankheit schreiben in der Psychiatrie um 1900? Diagnosen, Kranken- und Patientengeschichten von Opfern der nationalsozialistischen 'Euthanasie'-Aktion, 'T4.'" In Yvonne Wübben and Carsten Zelle, eds. Krankheit schreiben. Aufzeichnungsverfahren in Medizin und Literatur, 109-218. Göttingen: Wallstein.

Sirotkina, Irina (2002) Diagnosing literary genius: a cultural history of psychiatry in Russia, 1880-1930. (Medicine & Culture.) Baltimore, London: The Johns Hopkins University Press.

Slucevskij, Izmail F. (1957) Psixatrija. Leningrad: MEDGIZ.

Steinberg, Holger and Matthias C. Angermeyer (2001) "Emil Kraepelin's years at Dorpat as professor of psychiatry in nineteenth-century Russia." History of Psychiatry 12, 297-327.

Steinberg, Mark D. "Melancholy and modernity: emotions and social life in Russia Between the revolutions." Journal of Social History 41, 4, 813-841.

Suxanov, Sergej A. and Pëtr B. Gannuskin (1902) "K uceniju o melanxolii." Zurnal nevropatologii i psixiatrii im. S. S. Korsakova (Korsakov Journal of Neuropathology and Psychiatry) 6, 1170-1187.

Soukhanoff, Serge and Pierre Gannouchkine (1903) "Étude sur la mélancolie." Annales médicopsychologiques 18, 213-238.

Suxanov, Sergej A. (1906) O melanxolii. Sankt Petersburg: Izd. Zhurnala "Prakticeskaja Medicina".

Tammiksaar, Erki (2016) "Political atmosphere in Dorpat in Emil Kraepelin's period". Trames 20, 4, 403-416.

Vail Brown, Julie (1981) "The professionalization of Russian psychiatry: 1857-1911." PhD Thesis in Sociology, University of Pennsylvania.

Wübben, Yvonne (2012) Verrückte Sprache. Psychiater und Dichter in der Anstalt des 19. Jahrhunderts. Konstanz and Paderborn: Konstanz University Press.

Zilboorg, Gregory (1943) "Russian psychiatry - its historical and ideological background." Bulletin of the New York Academy of Medicine 19, 10, 713-28.