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Clinical Psychiatry in Imperial GermanyReview - Clinical Psychiatry in Imperial Germany
A History of Psychiatric Practice
by Eric J. Engstrom
Cornell University Press, 2003
Review by Nassir Ghaemi, M.D., M.A., M.P.H.
Nov 10th 2005 (Volume 9, Issue 45)

Scientific medicine in the nineteenth century peaked in Germany. Any young American physician who wanted to make a name for himself, such as the young William James, needed to pepper his resume with a post-graduate tour in a few German cities.  Germany was the font of culture and science, and it remained so until the rise of the Nazi state.  In psychiatry, the same pattern held.  And, indeed, it is perhaps not too much of an exaggeration to state that contemporary psychiatry still involves, to a good extent, ideas expressed by nineteenth century German psychiatrists.  In the world of bipolar disorder research, for instance, almost every other article begins with a citation from Emil Kraepelin, the author of the most widely read psychiatry textbook of the late nineteenth and early twentieth centuries, and the man credited with the basic definitions of schizophrenia and manic-depressive illness.  Further, researchers still refer to the ideas of Wilhelm Weygandt when they discuss mixed mood episodes, or Ewald Hecker when discussing cyclothymia, or of Karl Kahlbaum when discussing personality types.  Even when the German authors are not named, the relevant concepts are essentially the same as what those earlier psychiatrists had described.

In other words, contemporary psychiatry is greatly indebted to nineteenth century German psychiatry, and yet, at least for English-speaking readers, we have not had extensive or detailed histories of nineteenth century German psychiatry.  This book fills that void.  It is a work of impeccable scholarship by a native German author who is also fluent in English. (Engstrom is a Research Associate at the Center for Human and Health Services at Humboldt University in Berlin; he taught a course there which appears to be the basis for this book:  Madness in Imperial Germany).  Thus, as a reference, and a source of almost entirely German-language primary evidence, this book is quite meritorious.  Its main weaknesses lie in a rather dry, academic style, and a lecture-hall kind of repetitiveness.

The book is most useful for those who are already interested in nineteenth century psychiatry, but it is not likely to elicit that interest in those who are not already so inclined.  Nonetheless, if read with attention and interest, one can glean many fascinating and important facts, not only about nineteenth century German psychiatry, but also (given how much impact that era has on our own) about psychiatry in general.

The key theme of this book is that psychiatry evolved in the nineteenth century largely as a result of the exigencies of the profession -- what psychiatrists themselves wanted to do to enhance their professional status and to engage in their professional work -- rather than either simply due to the natural process of scientific progress (a common assumption among psychiatrists) or due to the impact of the state (as often implied by the anti-psychiatry movement).  Engstrom marshals plenty of data to support his view.

The basic story is as follows:  Psychiatry arose as a profession in the early nineteenth century with the rise of asylums.  When patients were chronically psychotic, and beyond any help either in general hospitals or within their families, they were sent to new hospitals built for them apart from the rest of society.  These asylums, developed on the new moral theory of insanity initiated by Philippe Pinel in France, sought to remove the stresses of daily life and to simply provide humane, custodial care to those with incurable insanity.   At that time, such endstage psychotic patients seemed quite similar in their symptoms, giving rise to the concept, developed by Neumann, of a single psychosis (Einheitpyschose).  Further, the asylums were set up rather as a family structure, with the head alienist (the physician in charge of the asylum) as the father, and the patients as children.  The alienists lived on the asylum and the custodial nature of treatment rather closely resembled the close affective attention of family members. Just as in families, however, this close authoritarian structure could lead to conflict and abuse.

In the cities, physicians in the universities began to propose the application of newly developing medical and statistical ideas to those with mental illness.  The leader of this group, the man who most single handedly transformed psychiatry in the nineteenth century, was Wilhelm Griesinger.  Griesinger's maxim was that mental illness was a brain disease (an idea later popularized again in the US in the 1980s and 1990s by the mental health advocacy movement) and he pushed for a more traditional medical approach to insanity.  Instead of merely custodial care in rural asylums, Griesinger argued for urban-based university clinics where the mentally ill could be more rapidly diagnosed and, hopefully, treated more quickly, before reaching that end-stage of insanity that led them to go to the asylums.  Through his own personal influence, and the rising tide of scientific medicine (with its emphasis on experiment, statistics, and organ pathology), Griesinger led the charge that transformed German psychiatry over the middle decades of the nineteenth century.

By the end of the nineteenth century, while asylums still existed for intractable cases,  university-based urban clinics had taken off, each with its own academic chair in psychiatry. Since patients came to attention more quickly in this setting, psychiatrists were able to observe earlier, more acute phase, symptomatology, rather than the chronic end-stage illness seen in asylums.  It was in this setting that Emil Kraepelin in the late 1890s made the observations that led to the abandonment of the unitary psychosis theory and the new model of schizophrenia and manic-depressive illness. 

Engstrom documents many of the fine details of these transformations: like the reduction in seclusion and restraint advocated by Griesinger, the philosophy of rapid admission and rapid discharge advocated by Kraepelin and others, the interplay of psychiatrists with the state in the courts and in adjudicating new social insurance laws (simulation of work injury was a problem then and now), and the development of clinical research and teaching.  I was most intrigued by two other features of this history: the antipsychiatry movement in Germany in the 1890s, and the concept of social prophylaxis in psychiatry.

It is perhaps a surprise to realize that antipsychiatry movements did not begin in the 1960s, but rather in the 1890s, just when psychiatry was becoming officially organized and professionalized.  (One might date the birth of modern psychiatry as an explicit profession to 1902, when it received accreditation in Germany as part general medical education, and when official licensing was enacted for the specialty).   In the 1890s, opposition to psychiatry was driven both from the right and left wings of German society. The left wing was represented by Protestant groups who had built their own mental asylums and sought to provide custodial care in place of secular mental asylums. These groups saw social activism as part of their religious duty, much like liberation theologists in later years.   The right wing was represented by an up and coming political party, Adolf Stoecker's Christian-Social Party.   Both groups attacked psychiatric asylums for reported abuses of patients' civil rights, the Protestant social activists primarily on humanitarian grounds and Stoecker's group primarily on libertarian grounds.  American psychiatry today is still beset by both left-wing (psychiatry is too biological and represents the powers that be) and right-wing (psychiatry impinges too much on individual rights) critics.  How little has changed.

The concept of social prophylaxis was developed in the late nineteenth century as psychiatrists were influenced by Darwinism and came to see mental illness as primarily hereditary. Since cures did not exist, prevention was the logical alternative.  Further, psychiatrists became engaged in social issues, as their attention spread in the university-based clinics to neuroses and alcoholism and other common problems. 

What intrigues me about these two aspects of that era -- antipsychiatry and social prophylaxis -- is that they most closely presaged what was to come.  Engstrom concludes that the rise of the antipsychiatry movement led to the further professionalization of psychiatry, as practitioners closed ranks behind Kraepelin's concepts and developed their own professional personae more clearly.  Another interpretation might be that the antipsychiatry movement predicted the fall from grace of biological psychiatry and all that Griesinger and Kraepelin stood for, as well as the concomitant rise of Freud and psychoanalysis.  nineteenth century German psychiatry was, at its core, brain-based, biologically-oriented, and research-focused.  While this description might sound like 21st century American psychiatry, it did not represent American psychiatry for most of the twentieth century, a period dominated by Freud and the speculative theories of psychoanalysis.  It is not without reason that the recent transition away from Freud and back to biology has been termed "neo-Kraepelinian".  And, it is also perhaps to be expected that there is a resurgence of anti-psychiatric movements.  What will follow is unclear, but if this historical pattern holds, perhaps we will experience a "neo-Freudian" revival.

As for the evolution of social prophylaxis, Engstrom never draws the obvious conclusion.  In the Nazi era in Germany, as well as in the US in many states, it led to the policies of enforced sterilization of many persons with mental illness.  In Nazi Germany, it also led to the mass murder of thousands of persons with mental illness, a story that has yet to be told in full.  Engstrom is perhaps better placed than almost anyone else to tell that story, if he wishes to turn his attention to a sequel to this book. 

Today we also hear in American psychiatry about prevention as a possible wave of the future. With the typing of the human genome, the possibility of genetic prevention has even been raised. Again we are reliving the past, and given what happened in Nazi Germany, we would seem to have much reason for caution.   The laudable aspects of prevention should not be ignored: there needs to be much more attention to public health measures such as attempts to reduce poverty, crime, stigma, and sexual and physical abuse.  In that sense, the agenda of social prophylaxis is perhaps the part of our psychiatric history that has been most ignored and that deserves to be most resuscitated.  Yet such work will have to be avowedly political and social, and not simply medical, and in that work a socially progressive psychiatry will have to contend with both its anti-psychiatry critics as well as with its own repressive past. 

In raising these questions for me, as a reader, Engstrom's book proved quite provocative.  If he can follow up on this nineteenth century history with a twentieth century analysis that pursues these problems, he might be able to help us find our way toward a better future in this "impossible profession."

 

© 2005 Nassir Ghaemi

 

Nassir Ghaemi, M.D., M.A., M.P.H., Associate Professor, Department of Psychiatry and Behavioral Sciences; Director, Bipolar Disorders Program, Emory University School of Medicine


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Welcome to MHN's unique book review site Metapsychology. We feature over 7800 in-depth reviews of a wide range of books and DVDs written by our reviewers from many backgrounds and perspectives. We update our front page weekly and add more than thirty new reviews each month. Our editor is Christian Perring, PhD. To contact him, use one of the forms available here.

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Metapsychology Online Reviews
ISSN 1931-5716