He who knows syphilis knows medicine.

—William Osler, co-founding physician of Johns Hopkins Hospital

In 1885, the Boston Medical and Surgical Journal made an observation: mental asylums in the United States were full. The journal noted that the number of patients had risen dramatically, with people wandering the halls of asylums with a jerky gait, grandiose illusions, and dementia—a collection of symptoms deemed “general paralysis of the insane.”

On the rise, too, was syphilis. In its late stages, syphilis also creates a jerky gait, grandiose illusions, and dementia. In 1885, it was unclear whether the rise in the insane was due to pathological disease or other influences. But in 1897, a causal link between these symptoms and syphilis was found thanks to German psychiatrists Richard von Krafft-Ebing and Josef Adolf Hirschl.

Krafft-Ebing and Hirschl knew that syphilis could only be contracted once, so they created an experiment where they injected the pus from sores of syphilictics into people suffering from general paralysis of the insane. If the patient became infected, they could say with certainty that the patient had not had syphilis before. However, none of the subjects became infected with the disease, leading Krafft-Ebing and Hirschil to conclude that not only had all of their patients’ been previously infected by syphilis, but that it was a disease that caused their psychiatric symptoms.

Thus, the biological theory of mental illness was born. The connection between the biological nature of syphilis and the undesirable psychological side effects of that illness led researchers to assume that all expressions of mental illness boiled down to a biological malfunction. Given the first neurotransmitter wasn’t discovered until 1921, and more robust science on the matter didn’t appear until the mid 1950s, neurologists at the turn of the century instead focused on what could be observed in autopsies. However, little progress was made. Common psychological ailments of the time, like hysteria and shell shock, left no visible sign of brain tissue damage. This lack of biological evidence bolstered the theories of Sigmund Freud, the father of modern psychology, to say: “The case histories I write should read like short stories and that, as one might say, they lack the serious stamp of science.”

The link between syphilis and mental distress came at a time when a concept called Social Darwinism was hitting its stride. Rooted in Charles Darwin’s theories—though he himself was not directly connected to the movement—Social Darwinists believed that human groups were subject to the same evolutionary principles as plants and animals. Natural selection and survival of the fittest could be applied to sociology, economics, and politics because, in their view, sociocultural ideals were inherently biological. Said another way, it was biology that determined if you were white, male, and physically fit, so therefore, natural selection should be applied. Practically, this meant that Social Darwinists believed the strong should see their wealth and power increase, while the weak should see their wealth and power decrease.

The connection between Social Darwinism and the rise of the global eugenics movement of the late 19th century and the first half of the 20th century is obvious: a group of intellectual white men decided the human race was “de-evolving,” and wielded their power and influence to reverse this perceived course by professing who should and should not bear children. This influence stretched into all white-collar industries, from major businessmen like the Carnegie’s and Rockefeller’s to legal theorists, academics, criminologists, and of course, psychiatrists.

The science—although “science” is a loose term given not a shred of evidence existed then or now to back up the theory—became so pervasive, that by 1914, 44 American colleges had introduced eugenics into their curriculum. Rooted in the language of protecting the average citizen from those who threaten the fabric of society thanks to inferior genes and beliefs (note the connection between the language being used at this time and the language surrounding both sides of modern American political movements), Social Darwinists pushed the idea that the species could not evolve if people of good stock mingled or procreated with undesirables. The undesirables, as you’ll remember from high school World War II history lessons, included everyone from Jews to Blacks to the “feeble-minded” and physically disabled.

As Dr. Boonie Burstow, Canadian feminist professor and psychotherapist wrote of the Social Darwinists a few months before her death in early 2020, “While they saw themselves as progressive and as following the dictates of modern science, what they were wrapping themselves in was a combination of hatred and pseudo-science for there was not a shred of credible evidence supporting their position.”

Again, note the connection between Burstow’s commentary on Social Darwinists of the early 20th century and the mental illness propaganda being pushed into the zeitgeist today.

It is at this time in history when the open practice of eugenics simultaneously becomes both obvious and insidious. In 1920, German psychiatrist and eugenicist Alfred Eric Koch and German jurist Karl Binding penned Die Friegabe der lernichtung Lebensunwerten Lebens, which translates to “Permitting the Destruction of Life Unworthy of Life.” This work directly led to the German T4 program, which allowed for the killing of disabled patients in institutions under the guise of mercy. In 1939, Hitler secretly signed an authorization protecting physicians and administration from any prosecution associated with the program. It was also this program that would develop the gassing chamber used throughout World War II.

To help identify who “qualified” for the T4 program, planners developed questionnaires that were distributed to patients in hospitals, old folks homes, and institutions. Worded and formatted in a way that appeared like a simple census to the average citizen, these forms were actually designed to parse out ancestry not of German blood, those suffering from schizophrenia, epilepsy, dementia, encephalitis, and other chronic psychiatric or neurological disorders, criminals, and those who had previously been institutionalized.

A group of prestigious physicians evaluated the forms and identified those deemed undesirable. After their identification, they were coerced from their institution and transported to their death in a gassing chamber. The families of the victims received an urn and death certificate noting a fictitious cause of death.

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In the next installment of A Brief History of Psychiatric Diagnosis, we’ll look at how the eugenics movement influenced the bible of all psychiatric diagnosis, the Diagnostic and Statistical Manual of Mental Disorders (DSM).