THE BURGHOLZLI CLINIC
Modern Western Psychiatry
Essay delivered before the Innominate Society of Louisville, Kentucky on April 14, 1998.
Perhaps American Psychiatry if not all of Modern Western Psychiatry owes no greater debt to a single institution than to the Psychiatric University Hospital Zurich (Psychiatrische Universitatsklinik Zurich) or the Burgholzli Clinic as it is more commonly known. When one considers the great minds in psychiatry associated with its illustrious past one can readily see why this would be a valid opinion. Persons like Bernhard von Gudden, Auguste Forel, Adolph Meyer, Carl Jung, Eugen Bleuler, and Manfred Bleuler to name a few. Two of its directors (Bernhard von Gudden, 1870-1872 and Eduard Hitzig, 1875-1879) were famous neuroanatomists. Their successor, Auguste Forel, also won fame as a neuroanatomist before later becoming a social psychiatrist long before this concept was created. As you may recall from my earlier essay on Forel, he was the first director who was a true Psychiatrist. He promoted abstinence from alcohol, a liberated sexuality, and ambulatory psychiatric treatment for Zurich's population. There is much more to be said of Forel's contribution to modern psychiatry, but I am getting ahead of myself.
In their excellent paper on the occasion of The Burgholzli Centenary, Palmai and Blackwell (l) reviewed the historical development of the Burgholzli and compared it with its closest counterpart in England, the Maudsley Hospital. As they note:
…Its (Burgholzli) establishment came in the wake of a worldwide change in attitudes towards mental disorder, ushered in by developing humanitarian ideas and altering medical concepts of psychiatric illness. The conditions prevalent in Switzerland during the mid-nineteenth century, and public reaction to them were similar to those in England forty years before, which had led social reformers of the time to instigate a Parliamentary Committee of enquiry into the 'madhouses of England'. The appalling circumstances which were exposed at the Bethlem Hospital and elsewhere in 1815 were still to be found in Switzerland during the 1850's. The mentally ill were herded together with the chronically sick, or segregated in an isolated cellblock where the more violent inmates were physically restrained in untreated, stone-floored cells. They were cared for by a hopelessly inadequate nursing staff under an untrained lay administrator, and so casual was the medical attention that a contemporary physician noted ‘how frequently a doctor did not know a patient had been ill until he was presented with a death certificate’. (1)
As in England some 50 years earlier, finally enlightened lay people of good conscience found "psychiatrists with imagination and ability to provide effective remedies"(l). As Henry Maudsley had done in England, it fell to …Griesinger who had moved from the more advanced German school of psychiatry to become professor of medicine at Zurich University. Both men were described as “self willed, impatient of control, and neglectful of regular classes as students,” yet both achieved considerable clinical responsibility before they were thirty. At twenty-eight, Griesinger published his famous textbook, Die Pathologie und Therapie der psychischen Krankheiten fur Aerzte und Studirende (1871) (Pathology and Therapy of Mental Diseases).
By 1860, Griesinger had founded a psychiatric clinic at the University of Zurich and within two years land had been purchased outside the town from publicly donated funds for the erection of a mental hospital. The project was designed with the help of Griesinger's friend, the German psychiatrist Heinrich Hoffman. In 1863 Hoffman expressed his hope that “the future Zurich Institution will be the best appointed and equipped amongst the lunatic asylums of Europe.” (1)
During the next five years the hospital was built in parkland outside the town overlooking the Zurichsee and with a view of the Alpine foothills. The design would become a model for later institutions in Switzerland and elsewhere throughout the world. There was a central administrative and communal block separating the two sexes into eastern and western wings where they were further segregated from north to south to provide accommodation for quiet, semi-quiet, restless patients. This basic design has since been modified by the addition of admission villas after 1903, special care units for patients in need of extra physical attention in 1930, a small observation ward in 1942, and recently, new workshops, and a gymnasium. In addition there were numerous outlying buildings such as barns, green houses, and the "witches house" which was a children's playhouse built for one of the Bleuler's children. Since the 1980's there have been numerous renovations including the creation of a modern multi-media library wing, a research wing, and various specialty units.
Griesinger continued his lectures in mental disease at the university, teaching that brain pathology was the key to psychiatry, regarding numerous "psychological" theories as unproved generalities. When he left Zurich in 1865, psychiatric teaching fell into abeyance until shortly before the opening of the Burgholzli in 1870.
The first Director of the Burgholzli, Bernhard von Gudden also came from Germany. He had been influenced by Conolly in England who advocated the principle of no restraint. He proceeded to apply this principle fearlessly, despite accusations of 'reckless irresponsibility'. Political and administrative animosity caused him to leave within three years. (This is pretty much the expected life span of any Medical Director of a public institution in the United States today - so not much has changed.)
Yon Gudden was followed in 1873 by Gustav Huguenin who was trained in pediatrics and left after only two years to accept a professorship in medicine at the University. Edward Hitzig was director for the next four years and like his predecessors political controversy marred and prematurely terminated his stay. As Palmai and Blackwell point out:
"The difficulties encountered by the hospital's first three directors were accentuated by their German origin and poor understanding of the local dialect, but sprang mainly from two more fundamental sources. All, like Griesinger before them, were primarily interested in the basic sciences and organic origin of mental illness. Von Gudden's main contributions were in brain pathology and animal experimentation. He performed early studies on selective ablation of the central nervous system and was the first to suggest a connection between the pyramidal tracts and the cortex… Hirzig together with Fritsch… had been the first to describe the response of the brain to electrical stimulation, refuting earlier ideas that the entire cortex was functionally homogeneous. Despite such achievements, the experimental and organic approach to patients led paradoxically to further dispute with staff and lay administration, who were not yet ready to accept fully the principles of non-restraint. Inhuman remedies, like the rotary chair and cold water hosing, were forbidden, and drastic physical treatments, such as purges and emetics, were reluctantly and cautiously applied. The few drugs used included chloral, the bromides, and opiates, but the emphasis in treatment was mainly on good hygiene and plenty of rest… it was scarcely surprising that no one appeared willing to undertake the post of Director to the 'Hell of Burgholzli'". (1)
In 1879, Auguste Forel, a young native Swiss psychiatrist, already on the staff of the hospital, accepted the task at the age of thirty-one, only five years after qualification and with scarcely two years' experience in psychiatry. Forel's appointment marked the real beginnings of the Burgholzli's worldwide reputation. He proved ideally suited to bridge the gap between the older organic experimental approach and the dawning psychotherapeutic ideas on which that reputation has come to be mainly founded.
Assuming the Directorship, Forel faced formidable challenges. As I wrote in my earlier essay presented to this society in January 1993:
…when Forel assumed the Directorship of the Burgholz1i, he inherited a government run institution which was in disarray. There were various abuses of the patients by the staff, financial and political corruption, with even a tavern and brothel on the hospital grounds. He and his young assistant Dr. Laufer had to literally fight with and drive off intruders who were disappointed in the closing of these local institutions. It is to Forel and his medical administrative abilities, often willing to struggle publicly and in the press with local politicians, that the Burgholz1i became one of the preeminent institutions for the mentally ill in Europe. (2)
Forel's organization of psychiatric teaching became a model in other centers for decades, and as early as 1888 he succeeded in making psychiatry a compulsory subject towards medical qualification.
One of his most outstanding students and subsequent colleagues at the Burgholzli was Adolf Meyer, whose commonsense ideas and practical approach were later to have profound effects on western psychiatry and its rigid organically oriented nosology. Meyer's later role as the "Father of American Psychiatry" would be a fitting topic for a future essay.
Forel introduced modern advanced treatment techniques at the Burgholzli Asylum and those that could not be adapted from elsewhere were invented by him. Parallel to S. Weir Mitchell's work in America, he introduced the "rest cure" which involved humane care, proper food and recreations, as well as cultural and educational pursuits for the patients. Forel is credited with having invented occupational therapy. In addition to arts and crafts, the Burgholzli had busy agriculture including gardens, orchards, crops, livestock, and a large winery.
As I had previously noted: "Forel became interested in hypnotism long before Freud and culminated this interest by studying with Bernheim at Nancy. In 1894, Forel published Hypnotism or Suggestion and Psychotherapy. This book went through many translations and revisions and was widely used as a textbook in Europe. Forel was a gifted hypnotist (in contrast with Freud) and trained many psychiatrists in the skill, including Eugen Bleuler who succeeded him as Director in 1898." (2)
Forel became quite concerned with the problem of alcoholism in his patients as they made up the majority of his patient population. He recognized that the condition was curable and understood the value of total abstinence. Much of his success was through an organization known as the Blue Cross, sort of a nineteen-century equivalent of Alcoholics Anonymous.
As a social psychiatrist he was particularly concerned with the problem of human sexuality. Some consider this to be his most important contribution. His book le Question Sexuelle was translated into sixteen different languages and was published in many editions from 1905 to 1931.
In addition Forel was in the vanguard of worldwide temperance movements, world peace, women's rights, social, penal, political, and educational reform movements. In his later years he became a major leader of the Bahai religious faith in Switzerland.
Forel was followed as Director by Paul Eugen Bleuler, who had been trained in Paris by Charcot and Magnan as well as his predecessor, von Gudden in Munich. As a native of the canton, he achieved a particularly close and sympathetic understanding of his patients, whose culture and dialect he shared. The accomplishments of this distinguished figure in the history of psychiatry would warrant a singular essay as his career can only be summarized here.
Eugen Bleuler was Director of the Burgholzli from 1898 till 1927. Under his leadership the Burgholzli became the first university clinic to apply Freud's psychoanalytical theories to the study of mental diseases, leading not only to a better psychological understanding of language, antisocial behavior, motor disorders, and mental symptoms, but to significant therapeutic intervention strategies. Bleuler's close association with his senior physician, Carl Jung, led to the development of ideas which established the "Zurich School" in its own right. Their work laid the foundation of modern dynamic psychiatry and coined much of its vocabulary, including such terms as affective abnormality, complex, ambivalence, autistic thinking, schizophrenia, and schizoid. In conjunction with Eugen Bleuler, Herman Rorschach evaluated his world famous projection tests at the Burgholzli.
As Palmai and Blackwell point out: "One of Eugen Bleuler's most practical contributions to modern therapy lay in his management of schizophrenia, where he realized the deleterious effects of prolonged confinement in an institution and advocated early discharge as soon as the acute symptoms subsided. He created the beginnings of community care by organizing a service to follow up discharged schizophrenics and facilitate their rehabilitation. For those who remained in hospital, he advocated regular work, often on the land, and trained his ward staff to interrupt the stereotyped patterns of the schizophrenic's behavior whilst still permitting the patient a maximum of individual responsibility. These practices were adopted and developed by Hermann Simon to become widely known as 'active' occupational therapy." (1)
Bleuler's Textbook of Psychiatry enjoyed much success and prominence and has become a well-deserved classic in the field of psychiatry. The pupils who studied at the Burgholzli during this period disseminated its teachings throughout the world: Karl Abraham in Germany; Brill and later, Oskar Diethelm in the United States; Ruemke in Holland; and Minkowska in France. Binswanger, who later introduced phenomenology and existentialism to psychiatry, also studied at the Burgholzli and practiced in Zurich.
Eugen Bleuler was succeeded by Hans-Wolfgang Maier who had already spent his entire professional life at the hospital. His interests centered on forensic psychiatry. He pioneered the acceptance of diminished responsibility, urged the need for psychiatric training of the judiciary, and advocated sterilization of sexual deviants. The latter position proved to be an embarrassment when he became the principal figure in a hospital sex scandal involving a former female patient.
Maier was Director of the Burgholzli from 1927 unti1 1941. During this period child psychiatry flourished under the leadership of Jakob Lutz. Behavior disorders were appreciated and child guidance clinics were instituted. Physical method of therapy became popular during this era. Sleep therapy was developed by Jacob Klaesi in 1920 so the way was paved for the future of Insulin Therapy in 1936, cardiazol in 1937, and E.C.T. in 1940. Psychosurgery was approached more cautiously and was not used at the Burgholzli until 1946.
Maier has largely been ignored by historians who merely note his passing of the mantel of the Burgholzli Directorship to the second of the much more famous Bleulers, Eugen's son Manfred. Manfred Bleuler had originally intended to practice surgery, but after an early and extensive training in neurology and psychiatry, he was appointed Professor of Psychiatry in Zurich and Director in 1942 and remained at that post until 1969.
We are fortunate to have in our audience this evening Dr. John Schwab who was a personal friend and colleague of Manfred Bleuler. I appreciate his good counsel and support in preparing this report. Drs. Bleuler and Schwab exchanged several visits between America and Switzerland. I personally had the privilege of meeting Dr. Bleuler on the occasion of his visit to our Department and Community in the mid 1970's. This turned out to be somewhat embarrassing as he happened to come at the time several of us junior faculty members and our wives who called ourselves "The Pig Roast Players" put on an entertainment involving a large pig roast followed by a musical skit spoofing our Department of Psychiatry. I shouldn't have worried as this kind of thing happened a lot at the Burgholzli. Dr. Bleuler was a very pleasant, kind, unpretentious man who seemed to have a good time even while we were roasting his host and James Miller then president of the University of Louisville as well as a professor in our department of psychiatry.
Manfred Bleuler accepted the Directorship during very troubled times in Europe. He had learned well from his father and was quite a master in juggling the demands administratively between education and research while trying to provide for the needs of patients as a regional psychiatric hospital serving the needs of all types of patients, acute and chronic, as there were no other public institutions.
Bleulers own work focused on several areas; cerebral disease (the acute and chronic brain syndromes) and endocrine pathology (the "endocrine psychosyndrome"). He emphasized the impact of the person's personality upon the expression of the individual clinical psychopathological syndrome. Bleuler placed great stress on the importance and value of the personal relationship and trust between patient and doctor.
During Manfred Bleuler's tenure his colleagues made significant contributions: Ernst's important monograph on the outcome of the neuroses, Willi's study concerning the effects of schizophrenic children on their parents, and Benedetti and Muller's work on the application of psychoanalytical methods in the treatment of schizophrenia. Stoll pioneered the study of hallucinogenic drugs such as LSD, and Angst has investigated the factors which may influence the patient's response to pharmaceutical agents and also continued the study of the epidemiology of schizophrenia.
At this point I would like to fast forward this talk to talk to you about the present day Burgholzli Clinic and share with you some slides and information from a visit there by my wife and myself last summer…
Visit to the Burgholzli Clinic
I had called our host, Dr. Isolde Eckle the day before our visit to let her know we had actually arrived in Zurich and were still planning to visit the Clinic. She sounded very nice on the phone and let us know they were expecting us. The Burgholzli was a short taxi ride from our hotel which was downtown close to the main train station of Zurich.
Wanda and I arrived early and took pictures of the outside and grounds of the famous clinic. The Burgholzli is in a bucolic setting overlooking the Zurichsee. The grounds and flowers were particularly beautiful. We also noticed there was a street named for Dr. August Forel who was the main research object of our visit there.
Dr. Isolde Eckle was very attractive, slender, fashionably dressed woman psychiatrist who is an Oberartz or senior registrar, the equivalent of one of my Clinical Directors who run a unit at the hospital. She is a German from Munich. There is a good bit of political rivalry between the Swiss and German doctors there. Politically a Swiss will always be the Director. She began our tour by showing us around several of the units, the new research building (which was actually a completely gutted out and renovated old wing), and the library wing.
The layout of the Burgholzli is wonderful, all single story with symmetrical wings each having its own courtyard not unlike our hospital except Central State Hospital is on a much smaller scale. It was originally designed for only about 350 patients which surprised me. I was expecting a design accommodating several thousand like the large old sanitariums in the United States.
We had a long session in the Archives Area with a Mr. Mosli who is a psychiatric nurse who has dedicated himself to keeping the historical materials and telling their stories. I think he was a bit amazed that I knew as much as I did about Dr. Forel and his times. Besides Forel I learned of von Gudden, Herzig, the Bleulers - Eugen and Manfred, and Adolph Meyer.
Next we went to a luncheon meeting with Dr. Hell, the Director. He couldn't have been nicer and was very generous with his time. We had an hour and a half together and of course Dr. Eckle was with us all day. Dr. Hell is 53 and has been Director since 1991. We had a very nice lunch at the patient-staff cafeteria which had a very nice terrace for outdoor dining. We talked about mutual administrative concerns.
The Burgholzli is a semi-open hospital so that half of the units are open half of the time. Like Central State Hospital, they take care of adults only and have general adult psychiatry units and specialty units, particularly geriatric psychiatry and dual diagnosis. They did not have the forensic patients that we have, and by and large the CSH population seemed more ill. They had a number of depressed, phobic and neurotic patients that would have been treated privately here. Dr. Hell was particularly interested in panic disorder and anxiety syndromes.
After lunch Dr. Eckle walked us out to the garden and greenhouse area. There was also the vestige of what must at one time been a very large orchard. In her high heels she walked us up a pretty steep nature trail to the "witches house" which was built for the children of one of the Bleulers. The Directors prior to Dr. Hell had all lived on the grounds. Today this little house is a pavilion for patients and staff to have cookouts and informal group sessions with a beautiful view overlooking the city of Zurich and the Zurichsee.
We then walked on down the trail to the point that it was blocked by a large iron and wooden fence that Forel had built to wall off the infamous Stefansburg. Dr. Eckle led us down to another area on the trail to try to find a way to get to it. The gates were all locked. Finally Dr. Eckle found a key on her ring that let us through. In all of her time there she had never been to Stefansburg so she was delighted that she got to show it to us... Today it is a large four-story home where some of the staff live, particularly the head gardener. We didn't go in for that reason but I got some good pictures.
After returning to the main buildings we toured a few more areas including their little patient-run gift store and the large music room where lectures are now held. Finally by late afternoon we called it a day and took a cab back to our hotel.
1. G. Palmai and B. Blackwell: The Burgholzli Centenary. Medical History, Vol X, 257-265, 1966.
2. J. David McNeely: Dr. August Forel-Pro Humanitate. Louisville Medicine. Vol.40, No. 11, 17-21, April 1993.