Clinical Psychiatry in Imperial Germany: A History of Psychiatric Practice (review)

During the second half of the nineteenth century, psychiatry in Germany underwent radical changes. Several shifts in the nosology, treatment, and conceptualization of psychiatric disorders were negotiated within the psychiatric community and proposed to the public. What makes this book on the subject special is that Eric Engstrom does not concentrate on discourses, public attitudes, total institutions, disease concepts, or patients' views—this task has been performed by many other authors. Rather, his interest is in the role of practitioners and institutions in shaping a "modern" clinical psychiatry as a medical discipline; thus, he concentrates on "problems and opportunities as defined by professional psychiatrists and state bureaucrats, as well as [on] the institutional and administrative context in which they operated" (p. 11).

In portraying the rise of the psychiatric profession in the arena of conflicting interests of alienists, academic psychiatrists, politics, society, administration, and economics, Engstrom does an excellent job. His book is well structured and clearly organized, with intertwining chronological and thematical threads. After an introduction he paints a clear picture of mid-nineteenth-century psychiatry's topography: psychiatric journals, associations, training, the asylum, and the public appearance of psychiatry are described in detail. The following chapter is dedicated to Wilhelm Griesinger's reform program, with special attention to his prophylactic ideas and the implicated redistribution of professional labor, from guarding the insane to caring or trying to cure. Next comes an outline of how psychiatrists tried to fit their discipline into the development of medicine as a modern life science oriented toward mechanism and the natural sciences. A clear account is given of psychiatric research between 1870 and 1880, "scientific psychiatry in a neuropathological key" (p. 98), and of the impact of the neuropathological training of psychiatrists "not only on psychiatrists' conceptualization of madness, but also upon their understanding of their work as medical professionals" (p. 99). Whereas this kind of research was basically performed under laboratory conditions, the reaction to this "laboratory science" put an emphasis on clinical research.

Focusing in the next chapter on the 1880s and 1890s, Engstrom uses the prominent example of Emil Kraepelin and his clinical research in Heidelberg to illustrate the shaping of psychiatry as a bedside science. He convincingly argues that Kraepelin, partly owing to administrative constraints, sought to come to reliable diagnoses by assessing a disease's prognosis. Reliable prognoses were the key to scientific reputation, to didactic efficacy, and to solving the problem of overcrowding in asylums. The urge for a sound psychiatric education in the medical curriculum in order to create "sentinels" among general practitioners who would be capable of diagnosing psychiatric disorders at early stages is the central topic of the following section. Finally, Engstrom analyzes the relationship between social prophylaxis and the creation of psychiatric polyclinics. Reform concepts like sanatoria for the lower middle class are evidence of the psychiatric profession's orientation toward prophylaxis under the influence of hereditarian theories, as well as of social pressure to prove its utility.

In his book Engstrom does not forget to mention byways of the development, without getting lost in details. All of his findings and descriptions are backed by illustrative case reports of prominent psychiatrists and their approaches. None of the important protagonists of German psychiatry between 1860 and 1914 seems to have been forgotten. Each chapter is readable and worth reading in itself. The price for this independence of the single chapters, however, is that certain statements seem to be redundant when the book is read at one sitting (like the psychiatrist's moan that patients were admitted too late to hospitals). Of course, this is a minor criticism that does not affect the value of this outstanding book, which is an important contribution to the historiography of psychiatry. It should not be missing from any library concentrating on psychiatry.