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Eric J Engstrom, Clinical psychiatry in imperial Germany: a history of psychiatric practice , Cornell Studies in the History of Psychiatry, Ithaca and London, Cornell University Press, 2004, pp. xii, 295, £29.95, $49.95 (hardback 0-8014-4195-1).

Few topics have captured the scholarly imagination more than Germany's history in the modern era. Many historians marvel at how disparate regions in central Europe, known mostly for their ages-old distinctiveness, united in the course of the nineteenth century to become the continent's leading industrial, military, and diplomatic power. Germany's leadership in the arts, medicine, and science has also attracted considerable scholarly attention, and its achievements in the medical specialty of psychiatry were no less formidable. Seemingly out of nowhere German psychiatrists—notably the Munich clinician Emil Kraepelin—emerged by the end of the nineteenth century as the acknowledged experts on the diagnosis, treatment, and prevention of mental illness. Psychiatrists from around the industrializing world flocked to Heidelberg, Munich, Halle, Berlin and other locales to learn from German teachers how to interpret, cure, diagnose, and experiment on mental illness, and returned to their home countries bent on putting what they had learned into practice. By the beginning of the twentieth century Germany had replaced France as the unofficial headquarters of world psychiatry, having risen from backwater status to global leadership in the space of only a few generations. Meanwhile, psychiatry arguably underwent its most revolutionary epoch in a long history that stretched back at least as far as the ancient Greeks. 
 
The transformation of German psychiatric practice in the second half of the nineteenth century is the topic of Eric Engstrom's long-awaited book, which for years to come will serve as an indispensable text on the subject. Easily the best English-language account of nineteenth-century German psychiatry, Clinical psychiatry in imperial Germany recounts the rise of the university psychiatric clinic in the period after German unification in 1871. Over these years, the university psychiatric clinic, normally situated in urban areas close to universities, superseded the asylum (where most psychiatrists had laboured in the first half of the nineteenth century) as the chief locus of psychiatric practice. The theory behind psychiatric clinics was that they enabled psychiatrists to treat patients in the early stages of their conditions when a cure was most likely, and study patients and their symptoms with a view to classifying mental illnesses as purely natural disease entities. Clinics also gave psychiatrists the opportunity to teach their subject within academic settings, in the process carving niches for their specialty within the wider medical profession and the burgeoning university system of imperial Germany. By contrast, asylums typically were large institutions located in rural settings and housing patient populations characterized by high rates of chronic (often geriatric) diseases. Whereas an asylum psychiatrist was as much an administrator and moral authority figure as a physician, the clinic psychiatrist prided himself on his scientific and academic credentials. The asylum physician was an “alienist”, literally living and working on the fringes of polite, bourgeois society, while the clinic psychiatrist was a scientific and medical expert whose knowledge governments depended upon to inform policy-making on such social problems as alcoholism, crime, welfare, and syphilis. The asylum psychiatrist was often viewed as living apart from society; the clinic psychiatrist was firmly embedded in the civic community. 
 
Engstrom argues that “therapeutic efficacy” cannot account for the meteoric rise of clinic psychiatry in imperial Germany. “[A]cademic clinics contributed relatively little in the way of new therapeutic procedures and techniques,” he writes (p. 12). Indeed, in his view, the reputation of academic psychiatrists depended on their renown, first as pioneers in research and education, and later as experts in public health, what in imperial Germany was often called race hygiene. Overall, the rise of the psychiatric clinic was a multi-faceted story involving a variety of relationships between (for example) doctors and patients, psychiatry and other medical specialties, instructors and students, researchers and their objects of study, and professionals and their society at large. In such a complex matrix of cross-cutting relationships simple theories about the medicalization of everyday life and the links between knowledge, power, and social control break down. Engstrom rejects the notion that clinic psychiatrists were part of a top-down exercise in social control designed to discipline unruly groups. “The motivations of the state” cannot entirely explain the expansion of psychiatry and institutionalized populations in imperial Germany (p. 202). Instead, clinic psychiatry was a maze of disciplinary practices and institutions “designed to maximize normalcy” (p. 9). It was this endeavour to exploit and adapt to the mounting demands placed on it by society, state, and populace that explains clinic psychiatry's remarkable ascendancy in imperial Germany. 
 
Engstrom is to be commended for his ability to unravel psychiatry's intricate web of social and professional relations. If there is one weakness in his book it is that, apart from a single endnote, there is no attempt to place imperial German psychiatry in a wider, international context. What was happening in the US, Britain, France, Italy, and other nations at the same time? How similar was the experience of psychiatrists in these countries to that of German psychiatrists? How dissimilar? If events in French or US psychiatry unfolded somewhat differently—as appears to have been the case—might such a contrast have made German psychiatry yet another example of the sonderweg thesis so popular among certain historians? The answers to these questions need not have occupied a prominent place in Engstrom's narrative, but they would have added analytical depth to an already fine book.