• Print

Dr. Death

Josephinum, Ethics, Collections and History of Medicine, MedUni Vienna
Hans Asperger, bottom right, with the staff of the Vienna Children’s Hospital, 1933

Long-deceased Viennese doctors, unless they’re called Freud, rarely make newspaper headlines. But one has recently done so on both sides of the Atlantic. On April 19, the academic open-access journal Molecular Autism published a detailed article by the Austrian medical historian Herwig Czech about Hans Asperger, the Viennese pediatrician whose name has since the 1980s designated a syndrome that forms part of the wider autism spectrum. Like many prominent Austrian medical figures of his generation, Asperger’s wartime record of involvement in some of the deadliest aspects of Nazi medical practice had long remained unquestioned or was glossed over. Now he stood exposed as having been far from an opponent of Nazi thinking; racial hygiene was, in fact, at the center of his beliefs.

The historian Edith Sheffer’s book Asperger’s Children was published a month after Czech’s exposé. Her research was contemporaneous with his and draws on the same archival sources, but books take longer. Hers is an impassioned indictment, one that glows with the heat of a prosecution motivated by an ethical imperative. She charges Asperger with a heinous medical crime: sending at least thirty-seven of his child patients to their deaths. Herta Schreiber, who had suffered meningitis and diphtheria, was just short of three when her de facto death certificate was signed, in part on the grounds that she was “an unbearable burden to the mother.”

Accused with Asperger is the whole of the Nazi ideological apparatus that converted a diagnosis—a highly personal form of human assessment—into the first rung of a routine killing machine. Finally, Sheffer wants to indict the entire capacious category of autism, which she argues includes too many different kinds of people alongside the high-functioning, often talented, but somewhat relationally challenged people who have been given the diagnosis of Asperger’s—a diagnosis that for the US has now been shifted, in the most recent Diagnostic and Statistical Manual of Mental Disorders (DSM), into the broader autism spectrum.

The term “autistic” originated with the talented Eugen Bleuler, director of the Burghölzli, the pioneering psychiatric hospital in Zurich. In the early part of the twentieth century some of Europe and America’s best physicians spent at least a season there. Bleuler valued Freud’s insights and took a cue from psychoanalysis in his efforts to attend to unconscious mental processes and listen to patients’ words. Among the staff was Carl Jung, whose patient Sabina Spielrein also became a well-known psychoanalytic practitioner and the teacher of the famous psychologist Jean Piaget. Patients were seen individually twice a day: doctors were instructed to write down everything they said, whether or not it sounded like nonsense.

In the detailed description of the group of schizophrenias he included in a 1911 book, Bleuler coined the term “autistic” to characterize thinking—something that, unlike many, he was certain was going on in his patients—and feeling that were more than usually introverted, self-absorbed, and lashed with fantasies. He said he owed the term to Freud’s “autoerotism,” which described an infant’s inner fantasy life prior to any engagement with the external world. Autistic thinking took place “in symbols, in analogies, in fragmentary concepts…in crude offenses against logic and propriety.”1 In Bleuler’s understanding, schizophrenic patients suffered from a breakdown in the relation between thoughts, feelings, and actions; from ambivalence (another new term, which Freud picked up from him), as well as from delusions and hallucinations. Freud folded the idea of autistic thinking into his own theory of the narcissistic state of earliest infancy, when inner and outer life were not distinguishable.

Autism as a separate diagnostic category did not exist for Bleuler, Freud, or indeed for any doctor until 1943. What brought it into being was the birth of a new field: child psychiatry, with its close observation of behavior and its measurements and assessments carried out in schools, hospitals, or institutions.

Bleuler’s patients were all adults. Children, if they were seen to be mentally ill or considered “deficient” in some way, were put in the care of hospital neurologists (as Freud had been, in his earliest medical position) or institutions. Then, throughout the 1920s, psychoanalytic thinkers like Melanie Klein and Anna Freud turned their attention to the inner life of the infant and child. Theories of child development soon arose, many of them based on the close observation of behavior. It was this latter emphasis on behavior rather than on inner life that tilted the balance toward the kinds of categories today’s DSM uses to classify mental disorders.

A stand-alone category of early infantile autism didn’t come into use until 1943, when the psychiatrist Leo Kanner published his “Autistic Disturbances of Affective Contact” in the journal Nervous Child. The article, heavily endebted to his Austrian colleagues Georg Frankl and Anni Weiss’s work in Vienna’s Curative Education Clinic, concentrated on eleven young patients, eight boys and three girls, who had been observed and assessed by a variety of diagnostic tests, plus parental reports. Kanner argued that despite the borrowing of Bleuler’s term, these children’s profiles were not precursors of adult schizophrenia. What they had in common was an “extreme aloneness.” They had no interest in others and had not established relationships with their parents or other children. They had, however, a good relationship to objects that didn’t change in appearance and position. Their speech was disturbed in various ways; they had an anxious and obsessive desire for sameness that manifested itself in repeated acts and speech. They also had excellent rote memory. Kanner’s children all had professionally successful parents, who he noted were not warmly affectionate toward their offspring: this led him to the rather unhappy later hypothesis that “refrigerator mothers” might have something to do with his small patients’ autism.

In Germany as well as Austria during the Nazi period, death, as Sheffer notes in her book, was often “a treatment option” for doctors. With the aim of purifying the state, Nazis designated not only Jews, Roma, and homosexuals as toxic subjects—the first two slated for elimination—but also the disabled, those of “inferior hereditary material,” patients in mental institutions, and children who were judged likely to become an ongoing drain on the public purse. Young people who didn’t or couldn’t conform, who were not gemeinschaftsfähig—able to demonstrate what Sheffer translates as “community competence”—regularly ended up in the so-called T4 euthanasia program, named after its headquarters, Tiergartenstrasse 4 in Berlin, home of the Charitable Foundation for Curative and Institutional Care.

In Vienna, whose population enthusiastically welcomed the Nazis, such children were sent to be murdered at the notorious Spiegelgrund, part of the Steinhof mental hospital complex in the Vienna Woods. Ironically, the Steinhof itself had been designed by the great architect of the Vienna Secession, Otto Wagner, in the reforming first decades of the century, when it had been seen as a pioneering project to improve the lives of the ill. “The child euthanasia program reveals an intimate dimension to extermination,” Sheffer writes:

Doctors personally examined the children they condemned. Nurses personally fed and changed the sheets of children they killed. They knew the children’s names, voices, faces, and personalities. Killings were typically done in the children’s own beds. Death came slowly, painfully, as children would be starved or given overdoses of barbiturates until they grew ill and died, usually of pneumonia.

Sometimes their brains or other body parts found their way into research jars—a fact only disclosed in the late 1990s.

Asperger was part of the assessment apparatus that determined the fate of such children. Though no death warrants signed in his name exist, and though he claimed, like so many of his countrymen did after the war—despite prior vocal enthusiasm or fellow-traveling—never to have been a Nazi sympathizer, it is clear from the archival evidence Sheffer expertly amasses that he knew he was signing off on children’s fates. Crucially, too, his notions of what constituted “autistic psychopathy” in childhood, which he described most fully in his 1944 treatise of the same name, were deeply influenced by Nazi ideology.

Earlier researchers, like the science journalist Steve Silberman in Neurotribes: The Legacy of Autism and the Future of Neurodiversity (2015), have claimed that Asperger—who lauded his autists’ special, if eccentric, talents—was neither a Nazi sympathizer nor a participant in the euthanasia program. Silberman, like many in the field, may have been relying on the redoubtable German developmental psychologist Uta Frith, who spread Asperger’s fame from her base in the UK and remained willfully blind to his implication in Nazi ideas and practices. Perhaps the photographs of him have counted in his favor. They show a tall, fair man of impeccable bearing who would look good in the short trousers of the Wandervogel, the boy-scout-like groups he and the Nazis favored. Asperger did use some positive language about the more educable children in his care, but Sheffer’s analysis clearly tilts the balance against him.

Born near Vienna in 1906, Asperger trained at the city’s university during the 1920s. It was a time when an experimental children’s clinic, focusing on Heilpädagogik—which Sheffer translates not as “therapeutic” but as “curative” education—flourished under Erwin Lazar. Like many other doctors and psychologists across Europe and in the US after World War I, Lazar was interested in “dissocial” youths and in distinguishing between the social, physical, and psychiatric reasons for their difficulties or criminal behavior. Ideas of therapeutic education abounded. August Aichhorn, who was persuaded by Anna Freud to run a child guidance center for delinquents alongside the Vienna Psychoanalytic Society, used these cases as the basis for his famous book Wayward Youth (1925). It was translated into many languages and reviewed in the UK by Donald Winnicott, the pioneering pediatrician and analyst.

Poverty, a desperate home life, and parental predations began to be seen as shaping these children’s psychological and mental lives and contributing to their delinquency. Yet once the social, the psychological, and the medical were conflated, it made a difference whether they were being assessed from the political left or the political right. For those in the latter group, a “wayward,” rebellious youth who didn’t fit into the normal cohort could land in a general category of undesirability—those “defective” individuals who were, according to right-wing politicians, a burden on the nation and, according to eugenicists, harmful to what we would now call the gene pool.

In Austria and Germany, as in the rest of the West since the nineteenth century, eugenic thinking was popular. In Britain—where it was launched in the 1880s by the statistician Francis Galton, Darwin’s half cousin, who was much influenced by his Origin of Species—the emphasis of such thinking lay largely on positive eugenics. Reformers both on the left and on the right supported intelligence testing and “breeding for the best,” in the hope that the general “standard” of the population would be raised. In Scandinavia, and particularly in Nazi Germany and Austria but also in the US, the emphasis was on negative eugenics. Forced sterilization programs for “undesirables” of all kinds persisted after World War II. North Carolina continued its enforced sterilization program of the “mentally defective or feeble-minded” until 1977. Five thousand of the 7,686 people sterilized there were black. Indeed, the wide acceptance of sterilization in various countries may be one reason that the Nuremberg Trials paid little attention to this heinous aspect of Nazi purification policy, which compounded sterilization with euthanasia.

Hans Asperger was a self-proclaimed eugenicist and a right-wing Catholic. He worked briefly with the staff of the progressive clinic that Erwin Lazar, a student of Bleuler’s, had led. It was in this clinic that many of the earliest ideas on autism originated, in particular with two of its talented staff who would soon emigrate to America. The Nazi sympathizer Franz Chvostek, who ran the so-called swastika clinic at the University of Vienna, became his ally, and he was abetted in his climb through the ranks when the Vienna Children’s Hospital was taken over by Franz Hamburger, an ally of Chvostek’s. Both men were known eugenicists and believed in mass sterilization. Hamburger fired most of the hospital’s Jewish staff, and in 1931 Asperger, aged twenty-five, became one of his early appointees.

In 1934 he was made head of the Curative Education Clinic, where he worked alongside the notorious Erwin Jekelius, an early SA member. With Hamburger, Asperger took part in the “Motorized Mother Advising” unit, traveling the Austrian countryside to provide medical advice to parents, but also creating a register of “hereditary feeblemindedness,” among other ills. After the Anschluss, Sheffer writes, Asperger’s other professional comrade, Jekelius, became “the most prominent figure in child and adult euthanasia in Vienna, directing the killing centers of Spiegelgrund and Steinhof.”

Asperger first mentioned “autistic psychopathy” in 1938, but it had already been described by two talented Jewish staff in the clinic earlier in the 1930s: Georg Frankl and his soon-to-be-wife, the psychologist Anni Weiss. In 1937 Frankl emigrated to the US with the help of Leo Kanner. At Johns Hopkins he worked with Kanner and eventually Weiss, who had emigrated in 1934 and spent a few years at Columbia. In Vienna they had together identified in high-functioning children “the disruption of affective contact” that became a classic part of the autistic spectrum. Asperger never credited his Jewish compatriots in his speeches or writings.

Sheffer probes Asperger’s affinities with Nazi psychiatry, particularly his use of the term for soulful belonging, Gemüt, at once an assessment of character and of unity with the Volk. A failure in Gemüt slipped into definitions of psychopathy: the term gemütlosen Psychopathen was applied to children who were withdrawn, willful, isolated, whose “confinement of the self…led to a narrowing of relations to their environment.” Not to conform or fit into the state’s stereotype of a healthy body and a healthy mind could mark one for elimination.

Children born out of wedlock, teenage loners, “delinquents,” unconventional adolescent girls whose stepfathers and stepmothers worried about their sexuality—all such undesirables could find themselves with a fatal diagnosis. Killings in Spiegelgrund began on August 25, 1940. By the end of the war, at least 789 children had perished under the euthanasia program; some had physical, some mental problems, and others simply didn’t conform to the time’s definition of “normal” and couldn’t, according to the doctors, be integrated into the community.

Sheffer dramatically incorporates the voices of the few children who survived the sadistic terrors of the psychiatric regime into her account, as well as extant case notes. This makes for an anguishing text. It also gives one pause. How did Uta Frith—who taught many of the neuropsychologists and cognitive psychologists who now lead the field and, in 1991, made the first English translation of Asperger’s text on autism—manage to overlook his Nazi affiliations? Sheffer tells us that Frith chose not to publish Asperger’s preface, which gives a clear indication of his Nazi sympathies. But then the city of Vienna, ever slow to acknowledge its record of active collaboration while pleading its “occupation” under Nazi rule, only memorialized the children who had been killed at Spiegelgrund in 2002. One of its chief euthanizing medics, Heinrich Gross, like Asperger himself, went on to have a successful postwar career.

Starting in the 1960s, the numbers of children with “autism syndrome” diagnoses rose and rose. Nonpsychoanalytic researchers gained prominence in the field and rejected Kanner’s theories about “refrigerator mothers.” Instead they favored measuring behavior to abet epidemiological research and the study of entire populations. What we now call evidence-based medicine, which focuses on statistics rather than individuals, was on its way. An epidemiological study in Britain by Victor Lotter in 1966 showed that autism was to be found in 4.5 of every 10,000 members of the child population. This number kept rising as institutions for the care of the mentally ill were closed throughout the 1960s and attempts were made by governments to integrate all children into the school system.

Manfred Bockelmann/© 2018 Artists Rights Society (ARS), New York/VG Bild-Kunst, Bonn
Johann K., who was killed under the Nazis at the Spiegelgrund ­children’s clinic, Vienna, 1943; drawing by Manfred Bockelmann, 2012

The figures also grew because the definition of autism syndrome now stretched to include children who had never acquired speech and might suffer from various kinds of “retardation.” With this reclassification, by 2006 the reported rate was 116.1 per 10,000. As the historian Bonnie Evans has noted, in France, where institutions for “retarded” children did not close, the numbers of people diagnosed with autism remained small.2

Meanwhile Britain and the US shared experts and evolving descriptive language for a range of behaviors and conditions that fell into the autism spectrum. In the third edition of the DSM, autism moved out of the diagnosis of adult schizophrenia to become a subcategory of “pervasive developmental disorders” (PDD). By the time DSMIV was published in 1994, the criteria for a diagnosis of autism were “a qualitative impairment in social interaction” and “communication,” plus “restricted, repetitive and stereotyped patterns of behavior, interests and activities”—all setting in before the age of three. The diagnosis also included a delay or abnormal functioning of symbolic or imaginative play.

Asperger’s name first appeared in English-language medicine in 1981, when the British psychiatrist Lorna Wing published an account of a syndrome she named after him, drawing on his 1944 treatise on autistic psychopathy. In that paper, Asperger described children, some of them “little professors,” who lacked the ability to interact with others. “Asperger’s disorder,” a new subcategory of PDD included in DSM-IV, was distinguished by the fact that children showed no delay or deficit in intelligence or cognitive abilities or verbal communication, but like other autistic children exhibited impairments in social interaction and behaved in repetitive and ritualistic ways. Soon, Asperger’s became widely known as the high-functioning end of autism. In the popular media it was variously attributed to nearly all men and certainly all nerdy men: brilliant computer geeks, scientists, husbands who never adequately looked at or spoke with their wives.

It is unclear whether this common usage contributed to Asperger’s disorder disappearing as a separate diagnosis from DSMV (2013) and being merged into an autism spectrum disorder. (Asperger’s remains in the International Classification of Diseases, which is maintained by the WHO.) We don’t know whether the autism spectrum will eventually emerge as a single neuro-developmental disorder with causes that scientists will track, whether the current pandemic is linked to environment or genes, or whether it’s a single disease at all (rather than a reclassification of various others).

What is clear is that by now the disparate cohort who bear the diagnosis of autism has grown hugely, and that for many such people their diagnoses have had a primary part in their self-definition. For some, this medical identity can urge them toward much-needed special care or special schooling. It can also have, as Sheffer indicates, a negative effect—perhaps like all group identities, which assume similarity where there is substantial difference. This book is dedicated to her son, Eric, who she indicates has suffered from the “act of classification.”

The philosopher of science Ian Hacking has wonderfully described the phenomenon of diagnostic categories “making up people.” A large set of social factors contribute to the popularity of a diagnosis, which in turn creates the lenses through which we see ourselves and others. The growth of the autism diagnosis has been set in motion by patient activism, statistical conflation, websites, blogs, and chat rooms, art exhibitions, provision of services specifically for that diagnosis, media portraits, Web and medico/political campaigns, books such as Andrew Solomon’s prize-winning Far From the Tree, and the attention of talented writer-doctors such as Oliver Sacks. All these combine to create a particular kind of being who, for better or worse, bears an identity that is a medical diagnosis, most often a psychiatric one that at once stigmatizes and destigmatizes. In Rewriting the Soul (1995), Hacking traced the noisy rise of Multiple Personality Disorder. That diagnosis has now all but disappeared.

Sheffer clearly wishes the diagnosis that bears Hans Asperger’s name would disappear, and indeed any “totalizing label based on varying traits” rather than a set of physiological causes. Autism imprisons children in a single classification and affects their being in the world and their treatment by others.

It may be that because of Sheffer’s work, as well as Czech’s, Asperger’s name will disappear from diagnostic classifications and fade from the popular consciousness. Whether that will suffice to dismantle the entire category of autism is doubtful. There are too many vested interests in the campaign for greater recognition, research funds, and services to sufferers. Campaigners, as well as many doctors and psychologists, are vocal in repeating that early diagnosis reduces parental anxiety and children’s loneliness, provides access to special schools, and helps children develop in the best possible way. Until another set of classifications arrives to deal with the considerable challenges that now go under this name, autism will likely be with us.

If I have one cavil with this impassioned book it is that Sheffer, in making her case against Asperger and Nazi mental health policy, perhaps too readily and speedily folds the enthusiastic and necessary reforms of the 1920s welfare state—with its far-reaching hopes of improvement for an impoverished class and hapless children—into the vicious Nazi state. Of the tireless medical reformer Erwin Lazar, she writes that while “seeking to improve the care of children,” he “expanded a system that in time would ultimately control and condemn ‘dissocial’ children.” It is true that a state that prioritizes society and the social good may end up creating an assessment apparatus with norms of behavior that sometimes lead to the ostracizing of those who are different and lack Gemeinschaftsfähigkeit or “community competence.” But this also happens in many states that prioritize individual rights and liberties and have no welfare apparatus whatever. As many countries after World War II have shown, welfare arrangements need not lead a state to do away with its own citizens.

  1. 1

    Eugen Bleuler, Dementia Praecox or the Group of Schizophrenias, translated by Joseph Zinkin (1911; International Universities Press, 1950), pp. 66–67. 

  2. 2

    “How Autism Became Autism: The Radical Transformation of a Central Concept of Child Development in Britain,” History of the Human Sciences, Vol. 26, No. 3 (July 2013).