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 21^st 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

Categories: Philosophical, Psychology