Clinical Psychiatry in Imperial Germany: A History of Psychiatric Practice

Just as French used to be the language of diplomacy, the language of psychiatry was once German. The foundation of modern psychiatric nosology as well as the study of mind-brain relations was laid in the state hospitals and university psychiatric clinics of the German Empire. German journals once enjoyed the status that American psychiatric publications have today, and it was to the university psychiatric hospitals of Heidelberg and Berlin rather than to Bethesda that keen young research-oriented psychiatrists the world over flocked.

Today, however, in scholarly terms, almost nothing is known about the history of psychiatry in Germany. Historians of psychiatry have tended either to entomb themselves in Freud’s Vienna or to muster rather dull histories of individual asylums, perfect for doctoral dissertations but otherwise rather limited. The great accomplishment of Engstrom’s book is that it dissects the guts of German academic and asylum psychiatry from the 1860s until the First World War. No other historian has Engstrom’s magisterial command of the primary published sources—decades of journal articles’ worth—nor has anyone forged into the archives as has Engstrom, looking at government and university administrative correspondence on the foundation of some 18 university psychiatric clinics before World War I. These clinics were the seedbed of modern psychiatry, and this book, therefore, is must reading for those interested in this history.

Readers will have to get past the first chapter, however. Able though Engstrom is as a historian—he teaches the history of psychiatry in Berlin—his own orientation is thoroughly antipsychiatric, and the book seeks to answer the question, How in the world did psychiatry ever get to be an independent profession? The answer, taken directly from French antipsychiatry historian Michel Foucault, emphasizes “discipline” and “control.” In this view, there is no such thing as actual psychiatric illness but only cultural perspectives endorsing a quite illegitimate power grab on the part of a bunch of control-hungry professors out to do society’s bidding or, even better, “capitalism’s” bidding, but most of all to expand their own influence over society. According to Engstrom, “The profession’s cultural machinery was designed to solve the so-called problem of insanity.” Insanity was a “problem” because the educated upper middle classes cherished reason, and “the madman’s flaunting negation of that concept became an object of particular consternation.”

Insanity, says Engstrom, has some positive aspects as well as problematical: “Obviously, it could also enrich the lives of those who confronted it.…Insanity could be seized as an opportunity for expanded self-understanding or alternative lifestyles” (p. 11). This will come as news to many patients as well as to most psychiatrists.

Readers willing to confront such postures will find definitive accounts of the foundation of Wilhelm Griesinger’s clinic in Berlin, where modern biological psychiatry began, and Emil Kraepelin’s years at Heidelberg, where the nosological concepts that ultimately gave rise to DSM-III in 1980 took form.

Putting Engstrom in the antipsychiatry school is not really a criticism of the book, any more than calling someone a Rosicrucian would be. It is a kind of global perspective that one either agrees with or not. Engstrom is so wrapped up in academic politics, however, that he loses sight of psychiatry as a discipline and argues, for example, that the university psychiatric clinics were little involved in actual patient care and little involved in therapeutic innovation. Both statements are wrong. There was scant therapeutic novelty in psychiatry before World War I, but thereafter the main innovations in treatment—Wagner-Jauregg’s malarial therapy for neurosyphilis, Klaesi’s deep sleep therapy, Sakel’s insulin therapy, Meduna’s Metrazol, and Cerletti’s ECT—came from university clinics (none, to be sure, in the German Empire but all profoundly influenced by German academic psychiatry). As for not being directly involved in patient care, university psychiatric hospitals had large numbers of beds. The Germans became world leaders in psychopathology because they studied their patients so carefully.

No historian of psychiatry has done such a careful job on the politics and sociology of these crucial decades in Germany, and Engstrom’s book will be on the shelf of any serious reader of psychiatric history.