International Relations in Psychiatry: Britain, Germany, and the United States to World War II 1580463398, 9781580463393

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International Relations in Psychiatry

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Rochester Studies in Medical History Senior Editor: Theodore M. Brown Professor of History and Preventive Medicine University of Rochester ISSN 1526–2715 The Mechanization of the Heart: Harvey and Descartes Thomas Fuchs Translated from the German by Marjorie Grene The Workers’ Health Fund in Eretz Israel Kupat Holim, 1911–1937 Shifra Shvarts Public Health and the Risk Factor: A History of an Uneven Medical Revolution William G. Rothstein Venereal Disease, Hospitals and the Urban Poor: London’s “Foul Wards,” 1600–1800 Kevin P. Siena Rockefeller Money, the Laboratory and Medicine in Edinburgh 1919–1930: New Science in an Old Country Christopher Lawrence Health and Wealth: Studies in History and Policy Simon Szreter Charles Nicolle, Pasteur’s Imperial Missionary: Typhus and Tunisia Kim Pelis Marriage of Convenience: Rockefeller International Health and Revolutionary Mexico Anne-Emanuelle Birn

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The Value of Health: A History of the Pan American Health Organization Marcos Cueto Medicine’s Moving Pictures: Medicine, Health, and Bodies in American Film and Television Edited by Leslie J. Reagan, Nancy Tomes, and Paula A. Treichler The Politics of Vaccination: Practice and Policy in England, Wales, Ireland, and Scotland, 1800–1874 Deborah Brunton Shifting Boundaries of Public Health: Europe in the Twentieth Century Edited by Susan Gross Solomon, Lion Murard, and Patrick Zylberman Health and Zionism: The Israeli Health Care System, 1948–1960 Shifra Shvarts Death, Modernity, and the Body: Sweden 1870–1940 Eva Åhrén International Relations in Psychiatry: Britain, Germany, and the United States to World War II Edited by Volker Roelcke, Paul J. Weindling, and Louise Westwood

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International Relations in Psychiatry Britain, Germany, and the United States to World War II Edited by Volker Roelcke, Paul J. Weindling, and Louise Westwood

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Copyright © 2010 by the Editors and Contributors All rights reserved. Except as permitted under current legislation, no part of this work may be photocopied, stored in a retrieval system, published, performed in public, adapted, broadcast, transmitted, recorded, or reproduced in any form or by any means, without the prior permission of the copyright owner. First published 2010 University of Rochester Press 668 Mt. Hope Avenue, Rochester, NY 14620, USA www.urpress.com and Boydell & Brewer Limited PO Box 9, Woodbridge, Suffolk IP12 3DF, UK www.boydellandbrewer.com ISBN-13: 978-1-58046-339-3 ISSN: 1526-2715 Library of Congress Cataloging-in-Publication Data International relations in psychiatry : Britain, Germany, and the United States to World War II / edited by Volker Roelcke, Paul J. Weindling, and Louise Westwood. p. ; cm.—(Rochester studies in medical history, ISSN 1526-2715 ; v. 15) Includes bibliographical references and index. ISBN 978-1-58046-339–3 (hardcover : alk. paper) 1. Psychiatry—History—20th century. 2. Comparative psychiatry—History—20th century. I. Roelcke, Volker, 1958– II. Weindling, Paul. III. Westwood, Louise, 1947- IV. Series: Rochester studies in medical history, 1526–2715. [DNLM: 1. Psychiatry—history—Germany. 2. Psychiatry—history—Great Britain. 3. Psychiatry—history—United States. 4. Cross-Cultural Comparison—Germany. 5. Cross-Cultural Comparison—Great Britain. 6. Cross-Cultural Comparison— United States. 7. History, 19th Century—Germany. 8. History, 19th Century—Great Britain. 9. History, 19th Century—United States. 10. History, 20th Century— Germany. 11. History, 20th Century—Great Britain. 12. History, 20th Century— United States. 13. Internationality—Germany. 14. Internationality—Great Britain. 15. Internationality—United States. 16. Interprofessional Relations—Germany. 17. Interprofessional Relations—Great Britain. 18. Interprofessional Relations— United States. WM 11.1 I605 2010] RC438.I58 2010 362.196’89—dc22 2010002420 A catalogue record for this title is available from the British Library. This publication is printed on acid-free paper. Printed in the United States of America.

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Contents Introduction Volker Roelcke, Paul J. Weindling, and Louise Westwood 1

2

3

4

5

6

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8

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Inspecting Great Britain: German Psychiatrists’ Views of British Asylums in the Second Half of the Nineteenth Century Heinz-Peter Schmiedebach Permeating National Boundaries: European and American Influences on the Emergence of “Medico-Pedagogy” in Late Victorian and Edwardian Britain Mark Jackson Organizing Psychiatric Research in Munich (1903–1925): A Psychiatric Zoon Politicon between State Bureaucracy and American Philanthropy Eric J. Engstrom Germany and the Making of “English” Psychiatry: The Maudsley Hospital, 1908–1939 Rhodri Hayward Patterns in Transmitting German Psychiatry to the United States: Smith Ely Jelliffe and the Impact of World War I John C. Burnham

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12

30

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“Beyond the Clinical Frontiers”: The American Mental Hygiene Movement, 1910–1945 Hans Pols

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Mental Hygiene in Britain during the First Half of the Twentieth Century: The Limits of International Influence Mathew Thomson

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Psychiatry in Munich and Yale, ca. 1920–1935: Mutual Perceptions and Relations, and the Case of Eugen Kahn (1887–1973) Volker Roelcke

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Explorations of Scottish, German, and American Psychiatry: The Work of Helen Boyle and Isabel Hutton in the Treatment of Noncertifiable Mental Disorders in England, 1899–1939 Louise Westwood

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10 Welsh Psychiatry during the Interwar Years, and the Impact of American and German Inspirations and Resources Pamela Michael

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11 Alien Psychiatrists: The British Assimilation of Psychiatric Refugees, 1930–1950 Paul J. Weindling

218

Selected Bibliography

237

List of Contributors

243

Index

245

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Introduction Volker Roelcke, Paul J. Weindling, and Louise Westwood The decades around 1900 were a crucial period in the making of the various national systems of health services, as well as the formation of the modern medical and social sciences. The field of psychiatry and mental health care can be understood as located at the intersection of these spheres. Here, concepts, practices, and institutions emerged that marked responses to the challenges posed by urbanization, industrialization, and the formation of the nation-state. Psychiatry had a considerable impact on the modes of perception and evaluation, and on the patterns of action toward contemporary social concerns and political issues. These psychiatric responses were locally distinctive, and yet at the same time they established, in part, influential models with an international impact. This volume addresses two important topics of late nineteenth- and early twentieth-century history. The essays deal with the transformation of psychiatry into one of the most contested and influential modern sciences; and they link this focus to broader issues of international relations and transfers of concepts, practices, personnel, as well as funds in a context of rising internationalism and nationalism. For instance, an orientation toward new career opportunities in the United States by European physicians in the context of innovative and flexible institutional structures and systems of funding may be documented for the 1920s; yet this orientation has found almost no attention in the historiography of psychiatry. Likewise, the impact of the transfer and variety of adaptations of diagnostic, therapeutic, and preventative concepts in mental health care in various local, regional, and national contexts has so far been neglected. The Kraepelinian classification and associated clinical and research practices and the program of the mental hygiene movement are examples of such concepts and related practices that had a broad international impact, while being generally embedded in local specificities. A further dimension that has so far been given little attention is the importance of the ideal of internationalism in the sciences, as opposed to the increasing political nationalism since the midnineteenth century.1

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In general, historical research in the international dimension of psychiatry has so far mostly followed two strands: First, since the 1990s, the emigration of German-speaking physicians has been looked at in a number of studies.2 These studies mainly focus on individual biographies and the political contexts, but pay little attention to the impact of this forced migration on psychiatric care and research in the receiving countries.3 A second strand of such historical literature, which classifies itself as “comparative,” contrasts features of psychiatric concepts, practices, or institutions in different national settings.4 However, recent approaches, for example on the multitudinous and close interrelations between institutionalized psychiatric genetics in Munich (Germany) and Basel (Switzerland),5 are indicative of a phenomenon of general importance; namely, that of the comprehensive cross-linking within the field of psychiatry that transcended national boundaries in the first decades of the twentieth century. This example points to a problem inherent in the application of comparative approaches to the history of medicine: the tendency to exaggerate the importance of the differences between the national contexts and entities (institutions, disciplines) to be compared. This tendency in comparative approaches is intrinsically linked with the danger of a historiographically inappropriate assumption of national self-sufficiency or even uniformity. Simultaneously, both the specificities of local or regional features are neglected, and, in particular, the high degree of effectiveness of international interactions in the form of mutual awareness, communication, cooperation, and even mutual dependence resulting from the flow of conceptual, material, and personnel resources is marginalized or even ignored. The international travels of physicians and scientists, and of concepts, practices, or material objects, have already been described for the early modern period.6 During the nineteenth century, the development of new communication technologies and means of transport led to a rapid increase in the availability of knowledge about other countries and the facilitation of travel and migration. New technological developments also led to the rise of internationalism, which included the process of internationalizing cultural, political, and economic practices, as well as the emergence of international movements, organizations, and related exchanges.7 However, international transfers were not neutral operations. Concepts and practices were acquired for particular reasons, their selection was determined by certain criteria, and their use served special purposes.8 Thus, processes of transfer and adaptation might, for example, have helped to strengthen the collective identity of a social group (such as psychiatrists or social workers). They might also have been used as arguments to push individual or group strategies in establishing or expanding new spheres of competence, or to facilitate the application of new practices and technologies.9 These historical phenomena necessitate conceptual and methodological approaches that go beyond analyses on the national levels, or comparisons

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as outlined above. Concepts such as transnational history and histoire croisée are attempts from political and cultural historiography to meet such challenges.10 For the purpose of analyzing international relations and transfer processes in psychiatry and mental health care, we suggest looking at a number of dimensions: personnel (study visits as well as migration); intellectual resources (including explicit and tacit knowledge); clinical practices; institutional models, organizations, and disciplines (such as “mental hygiene”); and finally, financial resources. The resulting patterns of mutual perception, inspiration, adaptation, and application of new concepts and practices open up a gamut of questions: What were the exact geographical (local, regional) origins, and what were the end points of transfer processes? In which temporal frameworks did they occur? Who were the initiators? Who were the main historical actors? To what extent were the transnational interactions, the travel of concepts and practices, or the migration of personnel, reactions to specific local, regional, or national circumstances and influences? What specific intellectual, institutional, and political configurations were in operation? In the case of the migration of individuals, what was the impact for the place, institution, or society at the point of origin of transfer and adaptation processes? And what was the impact for the place, institutions, or society at the point of reception? Did the processes of transfer and adaptation have simply an “additive” effect, or did they result in a new, transforming quality? The volume addresses theses issues by flexibly applying analytical frameworks that take up recent efforts to overcome national conceptions of history and capture transnational developments. In spite of rising nationalism in Europe, the intellectual, institutional, and material resources related to psychiatry and mental health care emerging in the various local and national contexts were rapidly observed beyond any national boundaries. In numerous ways innovations were adopted and refashioned for the needs and purposes of new national and local systems. Thus, during the mid and late nineteenth century, many German alienists (Irrenärzte, a common term for psychiatrists in the nineteenth century) and medical officers traveled to England, Wales, and Scotland to become acquainted with the different systems of mental health care, and to apply what appeared useful to the architecture and organization of new or restructured asylums in the German states and in the German-speaking contexts of Austria and Switzerland. The frequently selective use and adaptation of knowledge acquired by German psychiatrists in the course of such study visits to England and Scotland is addressed in the contribution by Heinz-Peter Schmiedebach. In the following decades, university departments and chairs in psychiatry were established at almost every German medical school, a process paralleled by the formulation of an apparently coherent system of terminologies, classifications, and related research programs for the description and analysis of psychiatric disorders, in particular by Emil Kraepelin and his school.11

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The direction of international travel was consequently reversed, and numerous, often young and scientifically aspiring psychiatrists from Britain, the United States, and other countries visited the new centers of psychiatric research and clinical practice in the German-speaking states. The broad and innovative establishment of German scientific institutions in the late nineteenth and early twentieth century, associated with new forms of research organization and massive funding through systematic public policies, resulted—amongst other developments—in the rapid extension of the laboratory sciences, including neuropathology and neurophysiology. This and the institutionalization of anthropological and genetic research after 1918 led to the establishment of a number of internationally renowned centers of neuropsychiatric research that held a considerable attraction for young scholars from Europe, North America, and Asia. The journeys, for example, of the American Smith E. Jelliffe or the British Aubrey Lewis to Heidelberg, Munich, and Berlin in the 1920s are an indicator for the attractiveness of both German neuropsychiatric laboratories and the Munich model of an academic clinic associated with a research institution.12 Thus, the German model had a considerable impact in the debates and activities leading to the foundation of the Maudsley Hospital and the associated Institute of Psychiatry in London, albeit with specific ambivalences, which are analyzed in the contribution by Rhodri Hayward: Whereas German psychiatry was initially a model to be emulated, especially with regard to funding methods, institutional organization, and Emil Kraepelin’s nosology, it later became, in the 1920s, a reference point, at least for some, to take a stance against Kraepelin and to distinguish British psychiatry from the political totalitarianism and the form of eugenic research preferred in Germany. And finally, after 1933, the German model represented a reservoir of talents that emigrated and could be recruited for British psychiatric institutions. Another level of complexity beyond simple unidirectional interpretation is outlined in John Burnham’s contribution to this volume: his essay explores the ways in which the psychoanalyst and medical journalist Smith Ely Jelliffe communicated with European counterparts, traveled to the Old World, and incorporated German and French research works into his Journal of Nervous and Mental Disease. The chapter sheds new light on a certain decline of scientific internationalism in the first half of the twentieth century that departs from an earlier openness for international exchange. Burnham also explicitly addresses cultural differences that hampered cross-border dialogues and mutual understanding. Whereas the Germans looked preferably to central state funding, others looked to philanthropic agencies. The leading institution for research funding in the 1920s and 1930s, the Rockefeller Foundation, decided in the mid1920s to invest considerable sums into the extension of German research programs and infrastructures in the neuropsychiatric sciences, particularly

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in the institutes of the Kaiser Wilhelm Society (a conglomerate of scientific research institutes financed by both state and private funds). Around 1930, this funding supported anthropological-genetic programs; the funds also aimed to further eugenic goals, contributing to a scientific legitimization of the eugenic agenda of the state. Remarkably, this funding was only decreased, but not stopped, after the Nazi takeover and in spite of the close cooperation of German medical geneticists with state and party authorities from 1933 onwards; it only ceased in 1939.13 This private support of eugenics research and infrastructures is best understood as part of a broader international interest in, and support for, eugenic programs, with related research in (human) genetics and the practical implementation of positive and negative eugenic measures. The historical actors were physicians and biologists, as well as teachers, lawyers, and politicians across the political spectrum; both state institutions and private philanthropic agencies supported eugenics programs.14 The Rockefeller Foundation also played an important role in building up international networks for neuropsychiatric research, facilitating what at the time was deemed best practice. Here, the medical sciences program officer Alan Gregg was central in directing funding toward studies of the biochemistry of brain function. He succeeded in bringing together and extending a network of young and innovative psychiatrists.15 The Rockefeller fellowships were prestigious opportunities for junior researchers to gain experience at centers of excellence. Institutions such as the Maudsley Hospital in London, the National Hospital, Queen Square, London, for the Relief and Cure of Diseases of the Nervous System, and the German Institute for Psychiatric Research in Munich, were massive beneficiaries of Rockefeller funds. One further aim of Rockefeller funding policies was to bring psychiatry into general medicine, as seen in the example of the Massachusetts General Hospital and the broader mental hygiene movement. Psychiatric illnesses were now seen as essentially curable. The Commonwealth Fund provided crucial support for child guidance programs, taking mental health work beyond the asylum and into the community. Here, psychoanalysis, social work, and more conventional child and adolescent psychiatry joined hands (see the contributions by Hans Pols and Louise Westwood). Evidence of such developments offers a contrast to narratives that depict American psychiatry as involved in a sinister “Nazi connection”16 to accelerate sterilization as the key thrust of community psychiatry. The need for philanthropic support is particularly evident in Britain, where hospitals were mostly charitable institutions with enormous problems in funding the day-to-day expenses, research, and salaries. The honorary appointment without salary was common in Britain; women doctors did long-term unpaid work because they were excluded from the well-paid appointments. Overt and covert discrimination in psychiatry kept most

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women out of the profession. The separatist strategy pursued by the few women who did break into the field precluded them from developing a high profile, but also allowed them more freedom in terms of innovative practice. This innovation is evident in the work of both Helen Boyle and Isabel Hutton, two woman psychiatrists described in the chapter by Louise Westwood. They were keen observers of psychiatric practice in Germany and America and they also compared and contrasted the gender relations and opportunities for women abroad with those in Britain.17 A massive transfer of intellectual and, in particular, of personal resources occurred from the 1920s onwards, and sharply increased after the political change in Germany 1933. The migration of German psychiatrists to the United States was initially motivated by new career opportunities in an apparently more open and flexible academic system. A case in point is Eugen Kahn’s move from Munich to the first chair of the Department of Psychiatry and Mental Hygiene at Yale University in 1930. As described in the contribution by Volker Roelcke, Kahn’s move shows the continuing influences from Germany to North America; in light of his ultimate failure at Yale, it also shows the impact of rapidly changing scientific and institutional contexts, and the problems of adapting knowledge and habits to new surroundings. After the Nazi takeover, the frequency of migration increased sharply, forced by the systematic Nazi policies against Jewish and Socialist physicians and researchers. Besides North America, Britain as well as other European and non-European countries were further destinations of the émigrés. Amongst other factors, the mediation by Frederick L. Golla and Aubrey Lewis in Britain, and by the Rockefeller Foundation in the United States, helped a number of psychiatrists to find refuge and temporary or tenured positions.18 Here, the issue is to what extent the émigrés had a modernizing influence on their surroundings—a topic addressed in the chapter by Paul Weindling. A number of iconic figures dominated psychiatry as an international science. It is rewarding to compare Adolf Meyer (Swiss born, later at Johns Hopkins in Baltimore) with Emil Kraepelin, the founder of the German Institute for Psychiatric Research in Munich and an advocate of national fitness.19 Similar to Meyer, Kraepelin was not only a figure inspiring individual psychiatrists and institutions internationally, he also relied greatly on international resources and reputation to create and sustain the Munich University Clinic and related Research Institute. Beyond the conventional emphasis on Kraepelin’s psychiatric nosology, Eric Engstrom’s contribution focuses on the realm of professional politics. He describes Kraepelin’s tireless efforts to gain institutional independence for his research while creating career opportunities for psychiatrists and soliciting funding from sources outside state budgets, including his attempts to establish contacts with American philanthropic organizations, which, however, were only partly successful. The

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question arises as to whether Kraepelin’s increasing nationalism became offputting for international visitors and financiers. Similarly, evaluating Ernst Rüdin, Kraepelin’s pupil and successor as director of the Research Institute, has become a matter of considerable controversy. Rüdin’s genetic methodology remained internationally attractive in spite of his cooperation with the Nazi regime, but the social implications of coercive sterilization and of forced killing of mental patients were abhorrent.20 The case of Adolf Meyer is an example of a Swiss innovator who migrated through Germany and Britain to the United States. He exerted a considerable influence in both the United States and Britain. The modifications of Meyer’s concepts while in the United States make it, however, difficult to see him as exercising a Swiss/German influence on American psychiatry. His diagnostic and patient-oriented approach involved an in-depth understanding of biological, psychological, and social factors.21 It came to have a profound effect on Scottish, and then British, psychiatry through David Henderson and other trainees, as outlined in the contribution by Paul Weindling. Meyer was also one of the coinitiators of the American, and then international, mental hygiene movement. In his contribution, Hans Pols gives an overview of this movement in the context of the major psychiatric developments in the United States, emphasizing the shift from Kraepelin’s system of classification to eugenic thinking, psychoanalysis, and finally a communityoriented set of public programs. Mathew Thomson’s chapter links to the chapter by Pols by providing an overview of the organizational history of the mental hygiene movement in Britain, its roots in specific British concerns with social “deviants” and the incapacitated, as well as its association with the American branch of the movement and its ultimate shift away from eugenics concerns. Thomson argues that mental hygiene became a social strategy that embraced public interest in psychology. Mark Jackson addresses the international roots of “medico-pedagogy” in Britain, an approach to so-called feebleminded patients that focused on physical education. It emphasized the practical use of patients’ manual work and, as such, reflected broader concerns regarding both degeneration and national efficiency in Edwardian society. Jackson underscores the British interest in German and American pedagogy, asylums, and auxiliary schools. Questions arise as to the relative backwardness of one or another country when judged in terms of scientific innovation or mental health care provision. Here different criteria can be used. As Pamela Michael suggests in a case study of mental health care and brain research at Cardiff (Wales), Britain in the 1920s had a sense of itself as backward in terms of clinical therapy and psychiatric research, but advanced in terms of the organization and management of psychiatric institutions. Questions also arise as to whether one can compare the (British) Board of Control with more decentralized U.S. and continental agencies.

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These exemplary case studies suggest that a unidirectional model of German influence on American and British psychiatry would be simplistic. Directions and patterns of influence were complex. Thus, we find that a category such as “mental hygiene” implied a more psychological approach, which originated from the United States, as well as a more biological and eugenic approach coming from Germany, and a third variant with roots in Britain. In sum, the case studies in this volume demonstrate that any up-to-date history of knowledge—and more specifically, that of scientific disciplines and medicine as practiced in hospitals and asylums—needs to take forms of transnational communication and transfer into account. As opposed to comparative approaches focusing on assumed national features, this transnational perspective allows us to identify processes on levels both “above” and “below” the national: It opens up the view for regional centers of knowledge in an international perspective—from Munich to Wales to New Haven; for the international activities of philanthropic institutions; and for the travels and migration of individual scientists as agents of change in a discipline that, like only a few others, oscillated between promising a better world through scientific expertise and being perceived as an instrument of state discipline and control. Heavily contested in the public sphere and highly charged politically, psychiatry, psychotherapy, and eugenics became vehicles to redefine both modern medicine and society in the first half of the twentieth century. Their story has so far been largely told as one of distinct national developments, from Germany’s rise to the status of a scientific world power to the United States’ presumptive status as the heir to European thought since the 1930s, when physicists, psychoanalysts, and many other medical specialists found a new professional home in America. This volume attempts to shed new light on developments that are only superficially known, bringing together hitherto separate strands, approaches, and results from the social, political, and cultural history of psychiatry and mental health care. It argues that modern psychiatry developed in a constant, though not always continuous, transfer of ideas, perceptions, and experts across national borders. Overall, this volume presents an alternative analysis that, instead of focusing on national features and contexts, broadens its perspective to include complex and multidirectional patterns of influence on regional, national, and transnational levels.

Notes 1. On the general context of internationalism in the late nineteenth and early twentieth century, see Elisabeth Crawford, Nationalism and Internationalism in Science,

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1880–1939 (Cambridge: Cambridge University Press, 1992); Martin H. Geyer and Johannes Paulmann, eds., The Mechanics of Internationalism: Culture, Society, and Politics from the 1840s to the First World War (Oxford: Oxford University Press 2001). 2. See, for example, Uwe-Henrik Peters, Psychiatrie im Exil: Die Emigration der dynamischen Psychiatrie aus Deutschland 1933–1939 (Düsseldorf: Kupka, 1992). 3. The impact of forced emigration by scientists has been analyzed in Mitchell Ash and Alfons Söllner, eds., Forced Migration and Scientific Change: Émigré GermanSpeaking Scientists after 1933 (Cambridge: Cambridge University Press, 1996); Werner Röder and Herbert A. Strauss, eds., Handbuch der deutschsprachigen Emigration nach 1933, International Biographical Dictionary of Central European Émigrés 1933–1945: Arts, Sciences and Literature (Munich: Saur, 1983). 4. See, for example, three stimulating volumes: Marijke Gijswijt-Hofstra and Roy Porter, eds., Cultures of Psychiatry and Mental Health Care in Postwar Britain and the Netherlands (Amsterdam: Rodopi, 1998); Roy Porter and David Wright, eds., The Confinement of the Insane: International Perspectives, 1800–1965 (Cambridge: Cambridge University Press, 2003); and Marijke Gijswijt-Hofstra, Harry Oosterhuis, Joost Vijselaar, and Hugh Freeman, eds., Psychiatric Cultures Compared: Psychiatry and Mental Health Care in the Twentieth Century (Amsterdam: Amsterdam University Press 2005). For the broader field of medical history, see, for example, Cay-Rüdiger Prüll, “Pathology and Surgery in London and Berlin, 1800–1930,” in Pathology in the Nineteenth and Twentieth Centuries: The Relationship between Theory and Practice, ed. Cay-Rüdiger Prüll (Sheffield: European Association for the History of Medicine and Health Publications, 1998), 71–99; Flurin Condrau, Lungenheilanstalt und Patientenschicksal: Sozialgeschichte der Tuberkulose in Deutschland und England während des späten 19. und frühen 20. Jahrhunderts (Göttingen: Vandenhoeck & Ruprecht, 2000). 5. Hans-Jakob Ritter and Volker Roelcke, “Psychiatric Genetics in Munich and Basel between 1925 and 1945: Programs—Practices—Cooperative Arrangements,” Osiris 20 (2005): 263–88. 6. A recent example is Harold Cook, Matters of Exchange: Commerce, Medicine, and Science in the Dutch Golden Age (New Haven: Yale University Press, 2007). 7. See, for example, Martin H. Geyer and Johannes Paulmann, eds., The Mechanics of Internationalism: Culture, Society, and Politics from the 1840s to the First World War (Oxford: Oxford University Press, 2001). For the sciences, see Mitchell Ash, “Internationalisierung und Entinternationalisierung der Wissenschaften im 19. und 20. Jahrhundert: Thesen,” Zeitgeschichte.at. Österreichischer Zeithistorikertag 1999, ed. Manfred Lechner and Dietmar Seiler (Innsbruck: Studien-Verlag, 2000), 4–12. 8. For an exemplary study of such selection and adaptation processes of French medicine in the United States, see John Harley Warner, Against the Spirit of System: The French Impulse in Nineteenth-Century American Medicine (Princeton: Princeton University Press, 1998). 9. For conceptual and methodological issues related to international transfer, see Bernd Kortländer, “Begrenzung—Entgrenzung: Kultur- und Wissenschaftstransfer in Europa,” Nationale Grenzen und internationaler Austausch: Studien zum Kultur- und Wissenschaftstransfer in Europa, ed. Lothar Jordan and Bernd Kortländer (Tübingen: Niemeyer, 1995), 1–19; and Michael Werner, “Maßstab und Untersuchungsebene: Zu einem Grundproblem der vergleichenden Kulturtransfer-Forschung,” Nationale Grenzen, 20–33.

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10. See Johannes Paulmann, “Internationaler Vergleich und interkultureller Transfer. Zwei Forschungsansätze zur europäischen Geschichte des 18. bis 20. Jahrhunderts,” Historische Zeitschrift 267 (1998): 649–85; Christopher A. Bayly et al., “AHR Conversation: On Transnational History,” American Historical Review 111 (2006): 1441–64; Michael Werner and Bénédicte Zimmermann, “Beyond Comparison: Histoire Croisée and the Challenge of Reflexivity,” History and Theory 45 (2006): 30–50. Thomas Müller has formulated the ambitious agenda of integrating comparative and transfer analysis for issues in the history of psychiatry, but on the empirical level has remained in the traditional categories of comparison: Thomas Müller, “Vergleich und Transferanalyse in der Medizingeschichte? Eine Diskussion anhand von Reiseberichten als Quelle,” Medizinhistorisches Journal 39 (2004): 57–77. 11. See Volker Roelcke, “Die Entwicklung der Psychiatrie 1880–1932: Theoriebildung, Institutionen, Interaktionen mit zeitgenössischer Wissenschafts- und Sozialpolitik,” in Wissenschaften und Wissenschaftspolitik: Bestandsaufnahmen zu Formationen, Brüchen und Kontinuitäten im Deutschland des 20. Jahrhunderts, ed. Rüdiger vom Bruch and Brigitte Kaderas (Stuttgart: Franz Steiner 2002), 109–24; Eric Engstrom, Clinical Psychiatry in Imperial Germany: A History of Psychiatric Practice (Ithaca: Cornell University Press, 2003); on the origins and establishment of Kraepelin’s terminology and classification, see Volker Roelcke, “Unterwegs zur Psychiatrie als Wissenschaft: Das Projekt einer ‘Irrenstatistik’ und Emil Kraepelins Neuformulierung der psychiatrischen Klassifikation,” in Psychiatrie im 19. Jahrhundert: Forschungen zur Geschichte von psychiatrischen Institutionen, Debatten und Praktiken im deutschen Sprachraum, ed. Eric J. Engstrom and Volker Roelcke (Basel: Schwabe, 2003), 169–88. 12. John C. Burnham, Jelliffe: American Psychoanalyst and Physician, and His Correspondence with Sigmund Freud and C. G. Jung, ed. William McGuire (Chicago: University of Chicago Press, 1983); Katherine Angel, “Defining Psychiatry: Aubrey Lewis’s 1938 Report and the Rockefeller Foundation,” in European Psychiatry on the Eve of War: Aubrey Lewis, The Maudsley Hospital, and the Rockefeller Foundation in the 1930s, Medical History, Supplement 22, ed. Katherine Angel, Edgar Jones, and Michael Neve (London: The Wellcome Trust Centre for the History of Medicine at UCL, 2003), 39–56. On Lewis, see also Michael Shepherd, A Representative Psychiatrist: The Career, Contributions, and Legacies of Sir Aubrey Lewis (Cambridge: Cambridge University Press, 1987); John Burnham, “The Transit of Medical Ideas: Changes in Citation of European Publications in USA Biomedical Journals,” in Actas del XXXIII Congreso International de Historia de la Medicina, ed. V. Juan Luis Carillo and Guillermo Olagüe de Ros (Sevilla: Sociedad Española de Historia de la Medicina, 1994), 101–12. 13. Paul J. Weindling, “The Rockefeller Foundation and German Biomedical Science, 1920–1940: From Educational Philanthropy to International Science Policy,” in Science, Politics, and the Public Good, ed. Nicholaas Rupke (Basingstoke: Macmillan, 1988), 119–40; Ritter and Roelcke, “Psychiatric Genetics in Munich and Basel,” 263–88; Volker Roelcke, “Funding the Scientific Foundations of Race Policies: Ernst Rüdin and the Impact of Career Resources on Psychiatric Genetics, ca 1910–1945,” in Man, Medicine, and the State: The Human Body as an Object of Government Sponsored Medical Research in the 20th Century, ed. Wolfgang U. Eckart (Stuttgart: Franz Steiner, 2006), 72–87. 14. See Frank Dikötter, “Race Culture: Recent Perspectives on the History of Eugenics,” American Historical Revue 103 (1998): 467–78; Paul J. Weindling, “International

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11

Eugenics: Swedish Sterilization in Context,” Scandinavian Journal of History 24 (1999): 179–97. 15. Weindling, “The Rockefeller Foundation and German Biomedical Science,” 119–40; Theodore Brown, “Alan Gregg and the Rockefeller Foundation’s Support of Franz Alexander’s Psychosomatic Research,” Bulletin of the History of Medicine 61 (1987): 155–86; William H. Schneider, “The Model American Foundation Officer: Alan Gregg and the Rockefeller Foundation,” Minerva 41 (2003): 155–66; Wilder Penfield, The Difficult Art of Giving: The Epic of Alan Gregg (Boston: Little, Brown, 1967). 16. Such an interpretation is formulated in Stefan Kühl, The Nazi Connection: Eugenics, American Racism, and German National Socialism (Oxford: Oxford University Press, 1994). 17. See also Louise Westwood, “Separatism and Exclusion: Women in Psychiatry, 1900–50,” Mental Illness and Learning Disability since 1850: Finding a Place for Mental Disorder in the United Kingdom, ed. Pamela Dale and Joseph Melling (London: Routledge, 2006). 18. For a review of Rockefeller support for medical refugees, see Paul J. Weindling, “An Overloaded Ark? The Rockefeller Foundation and Refugee Medical Scientists, 1933–1945,” Studies in History and Philosophy of Biological and Biomedical Sciences 31C (2000): 477–89. 19. See Eric Engstrom, “Emil Kraepelin: Psychiatry and Public Affairs in Wilhelmine Germany,” History of Psychiatry 2 (1991): 111–32. 20. On Rüdin’s international impact, see Volker Roelcke, “Die Etablierung der psychiatrischen Genetik in Deutschland, Großbritannien und den USA, ca. 1910– 1960. Zur untrennbaren Geschichte von Eugenik und Humangenetik,” Acta Historica Leopoldina 48 (2007): 173–90; on Rüdin’s involvement in Nazi selection policies, Roelcke, “Psychiatrische Wissenschaft im Kontext nationalsozialistischer Politik und ‘Euthanasie’: Zur Rolle von Ernst Rüdin und der Deutschen Forschungsanstalt/ Kaiser-Wilhelm-Institut für Psychiatrie,” in Die Kaiser-Wilhelm-Gesellschaft im Nationalsozialismus: Bestandsaufnahme und Perspektiven der Forschung, ed. Doris Kaufmann (Göttingen: Wallstein, 2000), 112–50; as well as Roelcke, “Funding the Scientific Foundations,” 72–87; on the broader context of Nazi health and social policy, see Paul J. Weindling, Health, Race, and German Politics between National Unification and Nazism (Cambridge: Cambridge University Press, 1989). 21. See Adolf Meyer, The Collected Papers of Adolf Meyer, 4 vols., ed. Eunice E. Winters (Baltimore: Johns Hopkins University Press, 1950–52); and Gerald N. Grob, Mental Illness and American Society, 1875–1940 (Princeton: Princeton University Press, 1983), passim. On Meyer’s influence, see Paul Weindling, John W. Thompson: Psychiatrist in the Shadow of the Holocaust (Rochester, NY: University of Rochester Press, 2010).

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Chapter One

Inspecting Great Britain German Psychiatrists’ Views of British Asylums in the Second Half of the Nineteenth Century Heinz-Peter Schmiedebach In the nineteenth century British asylums were large-scale buildings with luxurious equipment; they showed an extraordinary cleanliness that only the asylums in Switzerland could match; they provided the inmates with good or very good nutrition; and statistical registration of the insane had attained an enviable quality. Family care in Scotland was a model for the whole of Europe. This was the image that German psychiatrists visiting England and Scotland in the mid-nineteenth century had when they praised the British care of the insane. Such enthusiastic assessments were not only related to the mental health care system but also to surgery and public health. In 1836 the physician Adolf Mühry from Hanover praised English surgeons for their practical skills and pragmatic attitude.1 In 1873 the hygienist Max von Pettenkofer praised the English public health system and the sanitary conditions of British cities.2 The nineteenth-century British health care system was obviously seen as a highly attractive model for Germany. This view of British physicians resonated very well with a broader German cultural and political orientation toward the United Kingdom. A mutual exchange of ideas between British and German psychiatrists in the second half of the eighteenth and the first half of the nineteenth century has already been described by Max Neuburger more than half a century ago. He referred to the translations by German doctors of several British works on madness and related themes and, in a few cases, vice versa. He also addressed the mutual reception of theories on madness, but maintained that the idea of sin, guilt, and bad conscience as real origins of mental derangement, discussed by some German doctors in the early nineteenth century, would appear absurd to most English readers.3 In 1999, Wolfgang J.

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Mommsen pointed out that in the nineteenth century Great Britain and its political culture functioned as a model for the early liberalism in Germany.4 Several authors questioned the thesis of a German Sonderweg,5 although there were obvious differences between Britain and Germany not only in the role of the aristocracy but also in the function of parliament and the civil service.6 For instance, in the nineteenth century most German observers did not fully understand the parliament’s role in English public life. They misunderstood the significance of ministerial responsibility and tended to see it in terms of their own legal categories.7 Despite such cultural and political differences, it is indisputable that in the nineteenth century, a German-British cultural transfer took place, even if the motives of the persons involved were different in the two national contexts. In Germany, the motive for cultural transfer was to some extent due to political conditions such as “precensorship”; after the abolition of censorship in the early 1870s, the press was no longer relying on enthusiastic descriptions of English conditions as a replacement for criticizing concrete circumstances in Germany, but could roundly address the situation at home.8 Nevertheless, the publications of German psychiatrists also pointed to differences between German and British mental health care systems. These publications were part of a specific debate about the structure of the future German mental health care system; as a consequence, the questions and considerations of the German authors concerning conditions in British asylums were related to the issues and arguments used in the debate. Thus, we cannot expect to find an unbiased description of the British situation. The psychiatrists’ orientation toward foreign countries was used to support the arguments for their own position in debates at home, and to discredit the statements of their opponents. The images of the British mental health care system depicted by German psychiatrists therefore reveal more about the authors’ own position than about the reality of the British asylums. In the course of the nineteenth century, the focal points addressed in this debate about the structure of the future German mental health care system altered due to political and social changes in both Britain and Germany. One of the main issues in this discourse was the position of doctors, not only as medical experts within the asylums, but also as the decisive power in the whole system of mental health care. The British doctor’s status, marked by his real or alleged dependence upon nonmedical supervision, was one of the most crucial points of difference discussed by German psychiatrists. For example, the debate about “nonrestraint” of inmates was associated with the topic of subordination versus autonomy. Several German authors believed that in Britain, society, primarily represented by the lunacy commissioners and visitors, would insist on a high level of “nonrestraint.” The Germans associated such social oversight with a position of inferiority and

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dependence. blamed this situation on the “inferior” and dependent position of their colleagues abroad. In this context the idea of Wissenschaft (a broad understanding of science) played an important role. This German term was used in reference to research in the humanities and the social sciences, the natural sciences, and medicine, whereby medicine had not developed a separate and specific notion of Wissenschaft.9 The term was strongly connected with the establishment of academic disciplines at universities, as well as with teaching and broader educational agendas. This broad and unified notion of Wissenschaft claimed to involve a rigorous pursuit of “scientific” truth free of metaphysical or ideological presuppositions.10 It also implied that Wissenschaftler (scientists) had to carry out appropriate empirical research that aimed for “objectivity” and that was understood to be the basis for all further activities, e.g., teaching, expert statements, or medical treatment. Thus, in this perspective, scientists differed from those who used scientific research or technology for pragmatic ends by virtue of their genuine interest in a subject “for its own sake” rather than for utilitarian purposes.11 This programmatic position of epistemological independence was used to claim authority in explaining the world. The most important place of scientific research and education in this specific sense of “objective” and “disinterested” was the German universities. They were institutions of the state, and the German professor had the status of a civil servant. This position was seen as a barrier against special interests of political, social, or industrial groups, and was designed to maximize independent research. Although the idea of the modern university as developed by Wilhelm von Humboldt around 1810 opposed state influence on all research subjects and on internal affairs of the universities, in the course of time German professors embarked on a close alliance with state interests and often served the interests of the nation-state.12 The use of the term Wissenschaft not only included epistemological distinctiveness but also authority and power in relation to academic institutions and social and political issues. For the specific context of nineteenth-century psychiatry, the notion of Wissenschaft was an important factor in legitimizing the position of the German asylum director. This term may constitute another point of difference between British and German discourse on mental health care. The first part of this chapter contains an outline of early German publications on British mental health care from the first half of the nineteenth century. The second part deals with the debates on the proper location and organization of asylums in the 1860s and 1870s. The third part focuses on the emergence of a new type of asylum in the final decades of the nineteenth century, and on the contemporary German movement labeled “anti-psychiatry,” which criticized psychiatrists and attempted to integrate patients’ views of mental health care into the system.13

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Psychiatrists and Asylums in the First Half of the Nineteenth Century In 1845 Nikolaus Heinrich Julius from Berlin published an article titled “Progress of the British Mental Health Care System.” He reported on the “bill to amend the laws for the provision and regulation of lunatic asylums for counties and boroughs, and for the maintenance and care of pauper lunatics in England” formulated by Lord Ashley, Sir James Graham, and M. Vernon Smith. Julius reconstructed the statement of Lord Ashley and commented on it. Ashley had distinguished between curable and incurable patients and stressed that it would be extremely useful to render easy access to the asylums for the curably insane. Because the asylums were overcrowded, it was impossible to admit every curably insane person. Therefore, curable insanity would, in time, become chronic and in the end incurable. In order to avoid this detrimental development, the new laws to be enacted obliged the counties and boroughs to establish new asylums and to differentiate between the chronically incurable and the acute and curable cases of insanity.14 The topics addressed in this article were related to a comprehensive German debate that took place in the 1830s and 1840s about the nature of future asylums in Germany.15 In the first decades of the nineteenth century, psychiatric asylums in Germany had been established outside the cities and in the countryside. Initially, castles and former convents had to accommodate the new institutions. After 1830–40, however, specific buildings were erected to serve as psychiatric asylums. The leaders of the debate about future asylums were three directors of asylums who were also the founders of the Allgemeine Zeitschrift für Psychiatrie, the first German-language journal of psychiatry: Heinrich Philipp August Damerow, Carl Friedrich Flemming, and Christian Friedrich Wilhelm Roller, themselves all well-known psychiatrists. These middle-class alienists were promoters of the first asylums as “monuments of humanity.” They favoured the countryside for various reasons. This location reflected the natural philosophical bias in favour of the rural idyll. The curable patients were supposed to be mentally overhauled and brought to reason whilst having recourse to nature in isolation from the hustle and bustle of society. The exclusion of the lunatic from public life was considered fair and humane because they were integrated into a family setting where patients and staff lived together and shared the same communal facilities of the asylum; the patient’s isolation was viewed as a remedy. This approach relied upon an image of the city as a pathological location. Moreover, there were arguments against the city location for financial and administrative reasons, since property of adequate proportions was expensive in large cities.16 To ensure reasonable access to necessary supplies and services, some psychiatrists thought that the best compromise was the establishment of

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asylums about half an hour away from a city. However, the question of how to accommodate the curable and the incurable patients remained. Should the two groups be lodged in two separate asylums far away from one another, or should both groups be accommodated in one single asylum, each group assigned to a special wing of the building? In 1831 Roller devised a model that integrated “sanatorium” and “curatorium,” i.e., which combined the accommodation of the incurably and curably ill. This model became a blueprint for German asylum building for the next forty years. In 1842 the Illenau Asylum in Baden between Freiburg and Heidelberg was opened to house approximately three hundred patients and Roller became the first director. Three doctors, including the director, and about eighty employees worked there and the ratio of nurses to patients was about one to four. During the last decades of the nineteenth century this asylum was enlarged and at the turn of the century it accommodated about six hundred patients. Occupational therapy was given priority and about 30 to 40 percent of the patients worked regularly.17 The architecture structured by corridors separated male from female patients, as well as the curable from the incurable. The educated patients lived closest to the rooms of the doctors and the director, followed by the calm; the agitated persons and the raving mad were housed far away from the centre.18 Despite the fact that Roller and other asylum directors ruled as authoritarian patriarchs over the asylum’s “extended family” (Grossfamilie), clinical observation of the patients’ behavior, sometimes complemented by the postmortem investigation of the brain, became a common method of obtaining information about the supposed somatic basis of mental illness. This kind of research underlined the claim to scientific methods in the sense sketched out above. The directors of the newly founded asylums considered themselves both benevolent rulers of their own little kingdom and contributors to the scientific explanation of insanity. Some directors used or abused the inmates to build up an enclosed retreat and to repulse the influences of modern society, particularly the negative consequences of industrialization and urbanization.19 Paradoxically, then, this asylum model was an obvious attempt to create a small and stable microcosm of insanity within a changing and challenging social environment that was believed to cause mental illness by its accelerated rhythm of life and the tremendous demands of the modern world. Even in the medical journal associated with the political revolution of 1848/49, Die medicinische Reform, the Berlin psychiatrist Rudolf Leubuscher put forward an argument for a concept of modern psychiatry that placed the institution’s director in a paternalistic position. He described medicine as a humane and social20 Wissenschaft and maintained that psychiatry should also become a Wissenschaft that explained the phenomena of psychology.21 With respect to the situation in Berlin he complained about the crowded

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living and the bad sanitary conditions of the mentally ill at the Charité Hospital, and the lack of space for outside work for the inmates. He demanded autonomy for the director of the ward, and maintained that his authority had to be decisive for the whole arrangement of the setting.22 Apart from Leubuscher’s specific ideas for a modern form of psychiatry and the accentuation of the humane and social side of medicine, his statement about the role of the asylum director, published in the most important German revolutionary medical journal, was by no means different from the positions of the nonrevolutionary asylum directors. The attempts to reject the influences of society on asylums and doctors were led by some German doctors who visited Britain in the 1840s and 1850s. In 1848, Theodor Schlemm published a book that gave a positive assessment of the British mental health care system.23 However, the reviewer of this book, Willers Jessen, stressed the heavy restrictions of the medical directors of the asylums in Britain. He held that, as opposed to the development in France and Germany, where sensible and humane doctors initiated the reform of the mental health care system, the British parliament was repeatedly forced to legislative activity because of crimes committed against the mentally ill. The result was the establishment of the Board of Lunacy Commissioners, which had great power over the doctors. As a consequence, psychiatrists were directed by lawyers, and were subordinate to the administration, which made all relevant decisions; there was no regard for “scientific” needs.24 In 1856, Hermann Dick, director of the Klingenmünster Asylum, discussed “nonrestraint.” He did not totally reject the idea of abolishing mechanical restraint but believed that partial mild restraint was still necessary. He conceded that during the previous two decades, public care for the insane in Great Britain had been very effective, and that Germany should adopt several British achievements. “Nonrestraint” was in general fruitful for the development of life within the asylum. He thought that certain asylum buildings and a better internal management would make a reduction of restraint in Germany possible. Yet, in his article, Dick revealed the interesting difference between the German and the British systems of asylums—the position of the doctors. He was convinced that in England restraint had previously been practiced excessively, to the point of abuse; the response was a backlash of extreme “nonrestraint.” Dick believed that the lunacy commissioners were the most committed to “nonrestraint,” far more than the doctors themselves. He cited an English psychiatrist who said that the physicians were not free to act as they wished. The establishment and increasing dissemination of a system of “nonrestraint” was due to pressure from outside the asylums. Only a minority of the doctors supported this system of treatment. He also reiterated the view that English psychiatrists, not patients, were under restraint. Furthermore he referred to the widely practiced seclusion of agitated patients, which he viewed as another kind of restriction.25

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Dick maintained that in no country other than Germany were asylum members, both inmates and staff, united as a great family whose centre was the physician. The doctor created the atmosphere and made the asylum into a place of care and cure. Other facilities of the asylum, such as padded rooms, were of minor importance.26 He described the German asylum as a closed, self-controlled system. Its complete segregation enabled it to ward off the harmful influences of the surrounding society. In contrast to this psychiatric seclusion in Germany, the British system was an openly organized system. According to the German visitors, the influence of society, of the controlling boards and laymen, were so powerful that the control of the doctor was reduced to an unacceptable degree. This difference was primarily a difference of culture and politics and not of medical attitudes, knowledge, or skills. According to Dick, the opinions of the majority of English and German doctors about restraint were broadly in agreement. In contrast to German conditions, the English political culture empowered the laymen, and suppressed the power and influence of the medical experts.

Discussions in the 1860s and 1870s In 1861 Wilhelm Griesinger visited Britain and became an enthusiastic proponent of “nonrestraint,” which was put into practice for the first time in Germany by Ludwig Meyer in 1862.27 Griesinger not only pursued a policy of “nonrestraint” but also developed a new concept for psychiatric care. His intention was to open the asylums to society and to medical teaching. Although in the 1820s some university professors already taught psychiatry, sometimes in collaboration with the director of an asylum, the majority of the directors had rejected the transformation of “their” asylums into teaching hospitals. Moreover, they feared that contact between students and patients would result in harmful effects on the latter. Now, Griesinger attempted to combine humane treatment with scientific research. He believed that academic teaching and medical research on insanity needed more emphasis than in the past, and he no longer considered it necessary for the director to live within the asylum.28 Griesinger subdivided the mentally ill patients according to the duration of their illness, differentiating between patients with chronic and those with acute conditions. He no longer made the distinction between curable and incurable patients. On the basis of this new differentiation, he demanded two kinds of asylum: the urban asylum for the acutely ill, and the rural asylum for the chronically ill. Although the urban asylums were to be placed in a pleasant environment, they would need to be in close proximity to a city. Every major city, he thought, should have an asylum in its immediate vicinity for the proper accommodation and treatment of acute cases.29 These

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asylums were to be affiliated with the universities as clinical institutions so that the patients would be available for teaching medical students. Only the chronically ill were to be accommodated in rural asylums, which would be organized along the lines of agrarian colonies with family care as the standard of treatment. Patients could be transferred from one institution to the other, according to their status; thus the mental health system could adapt the form of accommodation to the individual patient.30 The discussion about the best system of mental health care reached a climax in 1868. At a meeting of the psychiatric section of the “Gesellschaft Deutscher Naturforscher und Ärzte” in Dresden, the majority of the assembled psychiatrists voted to continue the traditional policy of housing all classes of inmates in one asylum.31 Heinrich Laehr, one of the leading asylum directors, stressed that only large asylums could provide sufficient case material and deliver enough corpses for autopsy. He also disapproved of separating the acutely and chronically ill, arguing that the same physician had to observe the course of the illness in both classes of patients from beginning to end. The reports on the British asylums during the 1870s dealt with the wellknown questions of “nonrestraint,” family care, and the dependence of doctors upon official visitors and commissioners. In 1871 Carl Wilhelm Pelman, director of the Stephansfeld Asylum, discussed the advantages of the English system. He mentioned the use of corridors to separate patients and the adequate number of cells for seclusion. According to him, the success of “nonrestraint,” which he did not deny, was due to the use of seclusion in the early stages of the patient’s agitation. He maintained that this early seclusion was sufficient to render mechanical restraint unnecessary.32 Despite his positive description, Pelman also criticized the power of the committee of visitors, believing that these laymen had too great an influence on the management of the asylum. Such a high degree of authority by laymen would hardly be accepted by a German director.33 The activities of the British doctors were heavily restricted, and the number of physicians working in an asylum was seen as very small, and as a consequence physicians could neither carry out treatment according to the individual needs of a patient nor pursue medical research on insanity. He pointed out that in Haywards Heath, only four postmortem sections had been performed in 1868, and only in cases of sudden death, but not as a method of systematic pathological research.34 In 1874, Emanuel Mendel, director of a private asylum in Pankow, critically commented on the small number of doctors working in English asylums, and the conditions under which they were forced to work. He argued that because of the excessive powers of the commissioners, the doctors were overburdened. Mendel believed that this detrimental development was responsible for a revival of the use of restraint in the British mental health system and he presented some examples of restraint in the asylum at Colney Hatch from a commissioner’s report.35

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In the mid 1860s, university chairs of psychiatry had first been established at the medical schools in Munich, Würzburg, and Berlin. This was the beginning of a process of integrating psychiatric care with medical research and teaching that was to last up to the first decade of the twentieth century. It was accompanied by an optimistic attitude with respect to successful cures and toward a physiological explanation of insanity through pathological alterations of brain tissue. The equation of the lunatic with the somatically ill was used by psychiatrists to ask for the establishment of new asylums, which were proposed as modern hospitals for mentally ill people. In order to underline these demands and to find conducive arguments, the British example was again referred to. Mendel compared the situations in England and Prussia using statistical surveys. He praised the English statistics, which in his opinion were of much better quality than those of Prussia: In 1873 England had 60,296 mentally ill persons out of a population of 23,356,414, which implied a ratio of 1 lunatic to 387 persons. In 1871, Prussia counted 52,634 mentally ill persons in a population of 23,971,337, which was a ratio of 1 lunatic to 468 persons. Mendel maintained that the difference was a result of problematic statistical methods applied in Prussia, and concluded that the number of mentally ill persons recorded in Prussia was too low because 7,439 psychiatric patients had not been counted.36 He also looked at the number of mentally ill persons lodged in asylums, and found again a considerable difference. In England there were 52,803 patients living in asylums and 7,493 in family care or in their own families. In Prussia, only 11,460 lunatics lived in asylums and 41,174 were on their own or with families. Moreover, he compared the number of paupers in asylums and found that in England there were 37,879 whereas in Prussia only 8,617 paupers were accommodated in asylums. When considering the reasons for these differences Mendel assumed that the manifestations of insanity in England were the same as in Prussia. He discussed several possible points of explanation for the low numbers in Prussia, such as dense or sparse population figures, access to asylums, modes of payment, overcrowding of asylums, and finally the aversion of the population to the asylums. In order to address the reservations of the population, he believed that it was necessary to guarantee public access to the institutions. He completed his article with an enthusiastic appeal to the public authorities and demanded the establishment of many more asylums, which, he argued, was a duty to humanity and absolutely necessary.37 Thus, Mendel used British statistical data to support a program to extend the number of psychiatric asylums, which was in accordance with the views of German psychiatrists. Such a program required a large amount of public financial support. Psychiatrists were aware of this problem of funding. Looking for a solution to avoid the expense of building new asylums, they once again provided images from Britain to support their argument.

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In 1875 Friedrich Jolly, Professor of Psychiatry in Strasbourg, visited Kennoway Asylum in Scotland and then published an article on family care. He declared that more expense was inevitable for the cure and care of the insane in Germany, yet he recommended a special kind of care that was cheaper than a stay in an asylum. He pointed out that it would be better to reimburse families for the care of insane persons rather than build new asylums. Another suggestion in his article was that control should be extended to lunatics who up to this time had lived on their own or in families without medical supervision. Considering the high number of insane people in Prussia living outside the asylums, as presented by Mendel one year earlier (about forty-one thousand), it was not surprising that the psychiatric profession was attempting to gain access to this large but disseminated group of the mentally ill. Jolly concluded his article with praise for the Scottish model of family care outside the asylum system and recommended that similar organizations should be adopted by other countries.38

The New Asylums From the 1870s onwards, a large number of new asylums were established throughout Germany. They now followed a new architectural layout that consisted of detached pavilions disseminated in parks. In the Langenhorn Asylum in Hamburg, for example, which opened in 1892, approximately 1700 patients, male and female, were separated along a central axis dividing the area into two equal parts. The director’s quarters were far away from the central building. Relatively close to his house was the mortuary, linked to postmortem facilities, which represented one side of the scientific requirements. In addition to these buildings, which also housed an anatomical collection, the asylum provided well-equipped laboratories that were prepared for microscopic research.39 The public and private asylums were very different. The group of public asylums comprised first the university hospitals for psychiatry and neurology, second, the Provincial-Irrenanstalten, comparable to county asylums, and finally asylums established by the communities. The private asylums were made up of the denominational asylums run by Protestant or Catholic congregations, and the asylums owned by private persons or doctors. Despite the increasing number of newly built public asylums, they could not provide the facilities needed for the cure and care of the insane. In 1877, the German Reich had ninety-three public asylums and by 1904 that number had risen to 180. In Prussia the public asylums provided about 75 percent of all institutionalized care. In general, the private asylums had to fill the gap in all cases, and in particular for the long-term care of the chronically insane.40 In 1861 the physician Eduard Levinstein opened his own

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sanatorium in Schöneberg, near Berlin, which very soon became a private asylum. Because of the increasing number of insane persons and the lack of asylums, the municipal administration of Berlin had to look for further accommodation for the mentally ill. In 1870 the city administration signed contracts with Levinstein, and in 1885 his private asylum “Maison de Santé” in Schöneberg gave shelter to four hundred patients. The costs were now covered by community funds.41 Similar conditions existed in other areas of Germany. It was mainly the chronically insane needing long-term care that were transferred to these private asylums.42 Thus, the mental health system in Germany during the 1880s and 1890s suffered, according to contemporary psychiatrists, from too few asylums and inadequate facilities. Not surprisingly, the publications of that time that dealt with British mental health care referred again to the Scottish family care system. Two authors who reported very positively about the Scottish system were Ernst Siemerling43 of the Berlin Charité in 1886 and Wilhelm Julius König44 of the Berlin Dalldorf Asylum in 1896. König referred to the reports of doctors from twenty Scottish asylums, according to which the nursing staff of Scottish asylums was considered good, and even sometimes of excellent quality. He stressed the strict selection of staff, the elaborate training program, and the optional high-level examination. The number of insane persons as well as the number of inmates in Germany increased dramatically in the 1870s. Other European countries faced a similar situation. In Prussia the number of inmates grew significantly; in 1880 there were twenty-seven thousand cases treated in Prussian asylums and by 1910 that number had increased to one hundred forty-three thousand. Dirk Blasius argued conclusively that this process reflected the changing relationship between state and society as well as the transition from public care (Armutspsychiatrie) to governmental control (Ordnungspsychiatrie).45 Three Prussian governmental decrees, of 1894, 1896, and 1904, illustrate a growing interest by the administration and the police in the affairs of the mentally ill. In 1894, the state tried to obtain control over patients outside the asylums and the government took steps to bring such individuals into the asylums, thus, it was argued, guaranteeing public safety. On the one hand there were differing views amongst psychiatrists concerning the reasons for this increase in the number of insane persons and of inmates. Broadly speaking it was thought that the growth was caused by the establishment of new asylums, easier access to them due to the expansion of public transport systems, improvement of diagnosis, the higher ratio of incurable patients with long-term stays as compared to cured persons who could be discharged, and finally better hygiene and thus decreasing mortality of insane persons. On the other hand, however, the general population perceived the increasing number of committals to asylums with widespread disapproval. In the 1880s and 1890s there were several well-publicized attempts to get

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relatives out of asylums.46 Ann Goldberg described the story of the “liberation” of a Scottish priest in 1893 from the “clutches” of a Catholic insane asylum in the Rhineland.47 Beginning in the 1890s, a movement emerged that criticized psychiatrists and accused them of arbitrary deprivation of liberty and other crimes committed against lunatics. This movement consisted primarily of patients, lawyers, priests, and journalists. Between 1909 and 1921, the movement published a journal, which had a circulation of about ten thousand. The psychiatrists who were defending their position called this movement “anti-psychiatry.” Despite the aggressive tone of the articles, the movement’s aim was a general mental health law that would not only address grievances but also regulate the care and cure of lunatics and enhance the “scientific” character of psychiatry.48 The final aspect of asylum culture that is worthy of discussion is the work of patients in the production of goods and services in the newly established large asylums at the end of the nineteenth century. For example, the already mentioned Langenhorn Asylum not only produced all the milk needed for the inmates but also flowers and other plants for the hospitals of Hamburg. It ran a pig farm that sold eight hundred pigs a year on the general market.49 The economic aspects of asylum life became more and more relevant. The new type of asylum was a self-sufficient organism, centred on the steamer, machine house, and farm, and not around the dining hall or recreation facilities; it was partially integrated into the market economy. In 1912, the asylum industry was on the agenda of the meeting of the psychiatric society of the Rheinprovinz. Psychiatrists not only considered the kind of work that was appropriate for treatment but also the work that would best meet the economic needs of the asylum. It was discussed how the asylums could avoid unnecessary rivalry and the overproduction of goods. Several psychiatrists emphasized the main function of the asylum as a place for psychiatric purposes but it was also suggested that it would be useful to exchange patients that were suited for special requirements of particular production facilities at different asylums. Moreover, psychiatrists considered the question of whether it was necessary to specialize production in a single asylum or whether to establish a rich variety of producing sectors according to the manifold abilities of the inmates.50 Work and self-sufficiency influenced the psychiatric discussion on how to organize and structure the modern asylum at the beginning of the twentieth century. A considerable part of the inmates served as a cheap and disposable human resource for this production.

Conclusion During the second half of the nineteenth century, the structure and organization of asylums in Germany changed. There was a transition from a

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relatively small type isolated in a rural environment to a modern large type in close proximity to the cities. The first type was organized along a family structure with the director as an authoritarian patriarch ruling over his “extended family” (Grossfamilie). In contrast to this traditional structure and organization, the “modern type,” which was partially integrated into the market economy, was headed by a director who acted like the manager of a production company. The individual inmate of the modern asylum was subjected to a regime that differed according to the asylum’s production needs. From the 1890s, increasing governmental control brought more insane people, who had previously lived outside the asylum, into these institutions. All through the second half of the nineteenth century, German psychiatrists referred to the British example. On the one hand, by doing so, they instigated several internationally valid standards of mental health care, such as adequate accommodation, good nutrition, high quality statistics, family care supervised by a physician, and well qualified nurses. The British system was seen as being ahead of the German system in many respects, and the positive references to the British, and most particularly the Scottish model, were used as arguments in debates on the state of German psychiatry and asylums. On the other hand, German psychiatrists stressed the differences between the German and the British systems in order to reduce the influence of forces coming from outside the asylum. The debate on “nonrestraint” of inmates reveals those intentions because German psychiatrists did not reject the reduction of mechanical restraint in general, yet they insisted that the specifically British form of “nonrestraint” was a product of the ideology of laymen that ignored the experience of medical experts. Therefore they mostly criticized the exaggeration of this idea of “nonrestraint,” emphasized their solidarity with their medical colleagues abroad, and tried to prove that against all official statements the practical treatment in some British asylums required milder forms of restraint or seclusion, which was seen as another kind of restraint. Another point of critique concerned the subordination of the asylum’s doctors to lawyers and other laymen and the consequent low estimation of Wissenschaft by those who exercised control over the asylum. This subordination, combined with the small number of doctors working in the asylums, was seen to result in a neglect of medical research on insanity. According to the German doctors who visited British asylums, the scientific side of the mental health care system in Britain did not receive the support it needed. Several articles mentioned that in British asylums doctors did not perform pathological research. The high importance of Wissenschaft for the self-image of German psychiatrists was thus linked to this second difference between the two systems. This highly estimated ideal of Wissenschaft could produce impressive effects even outside the community of doctors: the “anti-psychiatric” movement of the late nineteenth century demanded, among other things, more

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Wissenschaftlichkeit (scientificity) for psychiatry and assumed that in this way the abuses of this medical discipline might be overcome. Thus, the reference to Wissenschaft in the German context implied the construction of an inner normative standard, and this is why German psychiatrists placed such great emphasis on it. With the reference to Wissenschaft they could attain the desired reputation without the unpleasant smell of arbitrariness. Wissenschaft stood for the self-controlling system of the scientific community; it could be used in order to legitimize the eminent position of the asylum director who did not want to subject himself to control by laymen. German psychiatrists could reject this kind of external control by referring to self-control by internal standards in the profession. A functioning “scientific” psychiatry could diminish the influence of laymen. The intensive consideration of the British system may therefore be seen as a consequence resulting from the confrontation of two different cultural concepts of control: the British lay leadership on the one hand and the German expert “scientific” leadership on the other.

Notes 1. Adolf Mühry, Darstellungen und Ansichten zur Vergleichung der Medicin in Frankreich, England und Deutschland (Hannover: Hahnsche Hofbuchhandlung, 1836), 194– 221. 2. Max von Pettenkofer, Über den Werth der Gesundheit für eine Stadt: Zwei populäre Vorlesungen, gehalten am 26. und 29. März 1873 im Verein für Volksbildung in München (Braunschweig: Friedrich Vieweg und Sohn, 1873), 14, 18, 39. 3. Max Neuburger, “British and German Psychiatry in the Second Half of the Eighteenth and the Early Nineteenth Century,” Bulletin of the History of Medicine 18 (1945): 139. 4. Wolfgang J. Mommsen, “Einleitung,” in Die ungleichen Partner: Deutsche–britische Beziehungen im 19. und 20. Jahrhundert, ed. Wolfgang J. Mommsen (Stuttgart: Deutsche Verlags-Anstalt, 1999), 9. 5. James J. Sheehan, “Some Reflections on Liberalism in Comparative Perspective,” in Deutschland und der Westen, ed. Henning Köhler (Berlin: Colloqium Verlag, 1984), 52. In 1986 Helga Grebing criticized the narrow dimensionality of the thesis of the German Sonderweg and claimed for a broader perspective with respect to the democratic traditions and to the history of the laboring classes in Germany; see Helga Grebing, Der “deutsche Sonderweg” in Europa 1806–1945: Eine Kritik (Stuttgart: Kohlhammer, 1986). 6. Rudolf Muhs, “Deutscher und britischer Liberalismus im Vergleich. Trägerschichten, Zielvorstellungen und Rahmenbedingungen (ca. 1830–1870),” in Liberalismus im 19. Jahrhundert. Deutschland im europäischen Vergleich, ed. Dieter Langewiesche (Göttingen: Vandenhoeck & Ruprecht, 1988), 223–59. 7. James J. Sheehan, German Liberalism in the Nineteenth Century (Chicago: University of Chicago Press, 1978), 46.

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8. Rudolf Muhs, “Geisteswehen: Rahmenbedingungen des deutsch-britischen Kulturaustauschs im 19. Jahrhundert,” in Aneignung und Abwehr: Interkultureller Transfer zwischen Deutschland und Großbritannien im 19. Jahrhundert, ed. Rudolf Muhs, Johannnes Paulmann, Willibald Steinmetz (Arbeitskreis Deutsche England-Forschung, 32) (Bodenheim: Philo, 1998), 61. 9. Fritz Hartmann, “In der Heilkunde wirksame Begriffe von Wissenschaft und die Frage nach einem möglichen Wissenschaftsbegriff der Medizin,” in Der Wissenschaftsbegriff in den Natur und Geisteswissenschaften (Wiesbaden: Franz Steiner, 1975), 57–88; Hartmann pointed out that medicine needs its own notion of “Wissenschaft” in order to integrate ideas of other disciplines and to focus them on the central problem of medicine—the practical side of medical care. 10. Alwin Diemer, “Der Wissenschaftsbegriff in den Natur- und Geisteswissenschaften,” in Der Wissenschaftsbegriff in den Natur und Geisteswissenschaften (Wiesbaden: Franz Steiner, 1975), 12–13. New challenges between 1870 und 1900 brought forward new methods of psychiatric research by Emil Kraepelin, who imported models from the laboratory and thus could develop a new program for clinical practice. See Volker Roelcke, “Unterwegs zur Wissenschaft: Das Projekt einer ‘Irrenstatistik’ und Emil Kraepelins Neufomulierung der psychiatrischen Klassifikation,” in Psychiatrie im 19. Jahrhundert. Forschungen zur Geschichte von psychiatrischen Institutionen, Debatten und Praktiken im deutschen Sprachraum, ed. Eric J. Engstrom, Volker Roelcke (Basel: Schwabe, 2003), 169–88. On the development of clinical psychiatry in the second half of the nineteenth century, see Eric J. Engstrom, Clinical Psychiatry in Imperial Germany: A History of Psychiatric Practice (Ithaca: Cornell University Press, 2003). 11. See Stephen P. Turner and Regis A. Factor, Max Weber and the Dispute over Reason and Value: Study in Philosophy, Ethics, and Politics (London: Routledge, 1984), 50–51. 12. Timothy Lenoir has scrutinized the way in which academic power in the second half of the nineteenth century was exercised by a group of modern physiologists and how their strategies for the implementation of their scientific beliefs fitted very well into the political and economic development of Germany. Timothy Lenoir, Politik im Tempel der Wissenschaft: Forschung und Machtausübung im deutschen Kaiserreich (Frankfurt: Campus, 1992), 18–52. 13. In 1998 Allan Beveridge published an article in which he analyzed more than a thousand letters written by patients between 1873 and 1908. Allan Beveridge, “Life in the Asylum: Patients’ Letters from Morningside, 1873–1908,” History of Psychiatry 9 (1998): 431–69. 14. Nikolaus Heinrich Julius, “Fortschritte des britischen Irrenwesens,” Allgemeine Zeitschrift für Psychiatrie 2 (1845): 512. 15. There are both specialized and general studies on the history of asylums. Important studies include Ann Goldberg, Sex, Religion and the Making of Modern Madness: The Eberbach Asylum and German Society, 1815–1849 (Oxford: Oxford University Press, 1999; Norbert Finzsch and Robert Jütte, eds., Institutions of Confinement: Hospitals, Asylums, and Prisons in Western Europe and North America, 1500–1950 (Cambridge: Cambridge University Press, 1996), which deals with a general historical theory of confinement; and the chapter by Christina Vanja, “Madhouses, Children’s Wards, and Clinics: The Development of Insane Asylums in Germany.”

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16. Cay-Rüdiger Prüll, “City and Country in German Psychiatry in the Nineteenth and Twentieth Centuries—The Example of Freiburg,” History of Psychiatry 10 (1999): 439–74. 17. Heinrich Schüle, “Grossherzoglich Badische Heil- und Pflegeanstalt Illenau,” in Deutsche Heil- und Pflegeanstalten für Psychischkranke in Wort und Bild, ed. Joahnnes Bresler (Die Anstaltsfürsorge für körperlich, geistig, sittlich und wirtschaftlich Schwache im Deutschen Reich in Wort und Bild, 7), vol. 1 (Halle: Marhold, 1910), 1–9. 18. Dieter Jetter, Grundzüge der Geschichte des Irrenhauses (Darmstadt: Wissenschaftliche Buchgesellschaft, 1981), 42. 19. See Heinz-Peter Schmiedebach, “The Mentally Ill Patient Caught between the State’s Demands and the Professional Interests of Psychiatrists,” in Medicine and Modernity: Public Health and Medical Care in Nineteenth- and Twentieth-Century Germany, ed. Manfred Berg and Geoffrey Cocks (Cambridge: Cambridge University Press, 1997), 105. 20. German psychiatrists did not use the term “soziale Psychiatrie” before 1903: Stefan Priebe, Heinz-Peter Schmiedebach, “Soziale Psychiatrie und Sozialpsychiatrie—Zum historischen Gebrauch der Begriffe,” Psychiatrische Praxis 24 (1997): 3–9. However, from the middle of the nineteenth century the term “sozial” was linked to medicine in numerous ways. The term described a communal or public perspective of medicine, according to which a large number of diseases were caused by damaging social circumstances. “Sozial” was also used to indicate political options relating to the social problems of society, and stood for the establishment of democracy, equality, welfare, education, and health; See Rudolf Virchow, “Mittheilungen über die in Oberschlesien herrschende Typhus-Epidemie,” Virchows Archiv 2 (1849): 143– 322. “Sozial” was also used in the sense of humane and philanthropic interaction, and this aspect was particularly relevant to doctor’s attitudes toward the mentally ill: Wilhelm Griesinger, “Vortrag zur Eröffnung der psychiatrischen Klinik zu Berlin am 2. Mai 1867,” Archiv für Psychiatrie und Nervenkrankheiten 1 (1868/69): 143–58. 21. Rudolf Leubuscher, “Die Stellung der Psychiatrie zur Medizin,” Die medicinische Reform 1/2 (1848/49): 95–97. 22. Rudolf Leubuscher, “Die Irrenverhältnisse Berlins,” Die medicinische Reform 1/2 (1848/49): 119–20, 127–29, 141–43. 23. Theodor Schlemm, Bericht über das britische Irrenwesen in Hinsicht auf Einrichtungen und Bauart der Irrenhäuser, auf Verwaltung und Heilkunde nach eigenen Anschauungen gegeben (Berlin: Albert Förstner, 1848). 24. Willers Jessen, “Schlemm (Th. Dr.), Bericht über das britische Irrenwesen in Hinsicht auf Einrichtungen und Bauten der Irrenhäuser, auf Verwaltung und Heilkunde nach eigenen Anschauungen gegeben. Berlin (Albert Förstner), 1848. X u. 225 S. Zwei Steindrucktafeln,” Allgemeine Zeitschrift für Psychiatrie 6 (1849): 100–113. 25. Hermann Dick, “Ueber das ‘Non-restraint-system’ in englischen und die Beseitigung der Zellen in französischen Irrenanstalten,” Allgemeine Zeitschrift für Psychiatrie 13 (1858): 353–425. 26. Ibid., 415. 27. Wilhelm Griesinger, “Die freie Behandlung,” Archiv für Psychiatrie und Nervenkrankheiten 1 (1868/69): 237.

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28. See Kai Sammet, “Über Irrenanstalten und deren Weiterentwicklung in Deutschland”: Wilhelm Griesinger im Streit mit der konservativen Anstaltspsychiatrie 1865–1868 (Münster: Lit, 2000). 29. Thomas Beddies and Heinz-Peter Schmiedebach, “Die Diskussion um die ärztlich beaufsichtigte Familienpflege in Deutschland,” Sudhoffs Archiv 85 (2001): 88. 30. Wilhelm Griesinger, “Ueber Irrenanstalten und deren Weiter-Entwickelung in Deutschland,” Archiv für Psychiatrie und Nervenkrankheiten 1(1868/69): 8–43. 31. Paul-Otto Schmidt, Asylierung oder familiale Versorgung: Die Vorträge auf der Sektion Psychiatrie der Gesellschaft Deutscher Naturforscher und Ärzte bis 1885 (Husum: Matthiesen, 1982). 32. Karl Wilhelm Pelman, “Reiseerinnerungen aus England und Frankreich,” Allgemeine Zeitschrift für Psychiatrie 27 (1871): 163–86, 307–34. 33. Ibid., 169. 34. Ibid., 173. 35. Emanuel Mendel, “Die Irrenverhältnisse Englands und Preussens,” Archiv für Psychiatrie und Nervenkrankheiten 4 (1874): 624–49. 36. Ibid., 626. 37. Ibid., 642. 38. Friedrich Jolly, “Ueber familiale Irrenpflege in Schottland,” Archiv für Psychiatrie und Nervenkrankheiten 5 (1875): 164–88. 39. Theodor Neuberger, “Die Irrenanstalt Langenhorn-Hamburg,” in Deutsche Heil- und Pflegeanstalten für Psychischkranke in Wort und Bild, 139. 40. Dirk Blasius, Einfache Seelenstörung: Geschichte der deutschen Psychiatrie 1800– 1945 (Frankfurt am Main: Fischer Taschenbuch Verlag, 1994), 64–65. 41. Insa Eschenbach, “Das Innere der Maison. Klassengesellschaft auch in der Maison,” in Maison de Santé: Ehemalige Kur- und Bezirksanstalt (Berlin: Bezirksamt Schöneberg von Berlin, 1989), 57. 42. See for example Wolfgang Schaffer, “Die Pflegeanstalt Mariaberg bei Aachen (1885–1900) und der Umbruch der provinzialen Geisteskrankenfürsorge auf dem Hintergrund des ‘Alexianerskandals’” Annalen des Historischen Vereins für den Niederrhein insbesondere das alte Erzbistum Köln 202 (1999): 155–92. 43. Ernst Siemerling; “Ueber schottische, englische, und französische Irrenanstalten,” Archiv für Psychiatrie und Nervenkrankheiten 17 (1886): 577–98. 44. Wilhelm König, “Einige Mittheilungen über den heutigen Stand des Irrenwesens in England und Schottland,” Allgemeine Zeitschrift für Psychiatrie 52 (1896): 229–57. 45. See Blasius, Einfache Seelenstörung, 61–115. 46. Ibid., 100–103. 47. Ann Goldberg, “The Mellage Trial and the Politics of Insane Asylums in Wilhelmine Germany,” Journal of Modern History 74 (March 2002): 1–32; see also Ann Goldberg, “A Reinveted Public: ‘Lunatics’ Rights’ and Bourgeois Populism in the Kaiserreich,” in Psychiatrie im 19. Jahrhundert. Forschungen zur Geschichte von psychiatrischen Institutionen, Debatten und Praktiken im deutschen Sprachraum, ed. Eric J. Engstrom and Volker Roelcke (Basel: Schwabe, 2003), 189–217; Cornelia Brink, “‘Nicht mehr normal und noch nicht geisteskrank . . .’: Über psychopathologische Grenzfälle im

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Kaiserreich,” WerkstattGeschichte 3 (2002): 22–44; for this analysis the author utilized many of the contemporary lunatics’ rights pamphlets. 48. Heinz-Peter Schmiedebach, “Eine ‘antipsychiatrische Bewegung’ um die Jahrhundertwende,” in Medizinkritische Bewegungen im Deutschen Reich (ca. 1870–ca. 1933), ed. Martin Dinges (Stuttgart: Franz Steiner, 1996), 127–59. 49. Neuberger, “Irrenanstalt,” 140. 50. Bernhard van Gülick, Die Geschichte des Psychiatrischen Vereins der Rheinprovinz 1867–1930 (Diss. med. Freie Universität Berlin, 1992), 270–73.

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Chapter Two

Permeating National Boundaries European and American Influences on the Emergence of “Medico-Pedagogy” in Late Victorian and Edwardian Britain Mark Jackson Some years ago, in his extensive account of the emergence of special education in Britain, D. G. Pritchard suggested that certain British pioneers, such as Mary Dendy (1855–1933), had been particularly influenced by “the Montessori method and its apparatus.”1 More recently, Carolyn Steedman has also identified Maria Montessori (1870–1956) as a pivotal figure in the translation of European educational styles to Britain.2 Although there were clearly similarities between the “medico-pedagogic” approach to the education of feebleminded children in British special schools and colonies around the turn of the nineteenth century and the “scientific pedagogy” developed contemporaneously by Montessori in Rome, it is unlikely that Montessori had a direct impact on British educational practices until the second decade of the twentieth century. Montessori had certainly visited London to study British approaches to mental deficiency in 1900, shortly after opening her “orthophrenic school” in 1899, but her work only became widely known after the translation of her seminal book into English in 1912,3 and her first official visit to England was not until 1919, nearly thirty years after the foundation of the first British special schools.4 In this chapter, I want to challenge previous historical emphasis on Montessori as the key influence on the origins and evolution of British educational approaches to feebleminded children by analyzing in more detail both the precise form and the complex ideological and pragmatic roots of British pedagogic practices in special schools and colonies during the closing decades of the nineteenth and opening years of the twentieth century. In doing so, I do not intend to comment extensively on the national educational policies or legislative reforms that emerged during the late Victorian

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and Edwardian periods, developments which have been covered in depth by an expanding literature on the history of mental deficiency on both sides of the Atlantic.5 Instead, this chapter will focus on the precise educational techniques employed in British special schools as well as on the educational philosophies that underpinned the elaboration, adoption, and dissemination of those techniques. In the process, I shall argue that early British pioneers of special education, and early formulations of “medico-pedagogy” for the treatment and education of feebleminded children, were more strongly influenced by the approaches of educationalists and psychiatrists in Germany, France, and Scandinavia and their American counterparts than specifically by the work of Montessori.

Medico-Pedagogy for the Feebleminded in England What became known in England as the medico-pedagogic approach to the training of feebleminded children emerged within a particular institutional context, and was shaped not only by certain educational ideologies but also by a variety of pragmatic and political considerations. Until the middle decades of the nineteenth century, children identified as “idiots” or “imbeciles” were usually cared for either at home or in general institutions, such as asylums for the insane or workhouses.6 During the 1840s and 1850s, however, a variety of philanthropic initiatives led to the creation of purpose-built institutions aimed at “educating the idiot” and reintegrating mental defectives into society. Idiot asylums such as the Royal Earlswood in Surrey, the Royal Albert in Lancaster, and Starcross in Exeter thus admitted mentally defective children for a period of between five and seven years, during which they were taught a variety of predominantly manual skills aimed at equipping them for work in the community.7 In addition to these charitable institutions, there were occasional municipal ventures in this area, most notably in London where, during the 1870s, the Metropolitan Asylums Board established first the Hampstead and Clapton Asylums, and subsequently the training schools at Darenth Park, for idiot children.8 The pattern of special educational provisions began to change after the introduction of “payment by results” with the Revised Code of 1862 and the emergence and enforcement of compulsory elementary education in the 1870s. The growing recognition that some children, although not idiotic or imbecilic, apparently could not cope with, or benefit from, an ordinary elementary education led to calls for special classes and special schools for such defective children. While many children labelled as backward or feebleminded certainly remained in ordinary schools, an increasing number of children were transferred to the special schools that were established in the early 1890s by school boards around the country, first in Leicester and London, but

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shortly afterwards in Nottingham, Birmingham, Bradford, Brighton, Bristol, Plymouth, and Manchester. Segregation in special schools of this nature was legitimated by reference both to the rights of all children to an appropriate education and to the benefits (both to “normal” children and to society) of removing problematic children from ordinary classrooms.9 However, by the last decade of the nineteenth century when special schools and classes were becoming more popular, the tone of debates about the feebleminded was shifting. Amidst concerns that feebleminded children inevitably became delinquent and criminal adults, as well as broader anxieties about racial and social degeneration, the humanitarian and educational aspirations of mid-Victorian doctors and reformers were increasingly overshadowed by a pessimism that permeated both the classification and management of mentally defective children. Growing public and political interest in the “problem of the feebleminded” precipitated strident calls for more effective regulatory measures designed to permanently segregate mental defectives in residential institutions. The aim of reformers such as Mary Dendy, Ellen Pinsent (1866–1949) and Dr. Alfred Tredgold (1870–1952) was to admit feebleminded children to residential schools where they would be trained for productive work in an isolated rural colony. Dendy’s institution at Sandlebridge in Cheshire, which was opened in 1902 by the Lancashire and Cheshire Society for the Permanent Care of the Feeble-Minded, became an effective blueprint for subsequent legislation: the Mental Deficiency Act of 1913 and the Elementary Education (Defective and Epileptic Children) Act of 1914 authorised the creation of a system of continuous control of the feebleminded, almost from the cradle to the grave.10 These developments provided the institutional and social context in which late Victorian and Edwardian doctors began to elaborate a particular educational approach to the feebleminded. The medico-pedagogic approach to mental deficiency, as it became known, was to comprise “a combination of hygienic and appropriate medical treatment with specially adapted physical, manual, and educational exercises,”11 designed to educate the senses and develop the intellect in a manner that imitated as closely as possible “the mode in which nature herself proceeds in the development of the faculties of perfect children.”12 Although stressing the importance of physiological (rather than psychological) principles, and although focusing on the central role of doctors, the medico-pedagogic approach also emphasised the effective cooperation of doctors, teachers, and nurses. The distinct medico-pedagogic method of developing the feeble mind that was devised by British medical practitioners was based on a number of principles. In general terms, medico-pedagogic approaches were grounded in the dictum mens sana in corpore sano.13 By highlighting the importance of restoring and maintaining bodily health by creating an appropriate physical and educational environment, this approach prioritized the role of doctors

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in managing the feebleminded. More particularly, however, advocates of the medico-pedagogic method stressed that education of the feeble mind could only be achieved through the body, a notion that comprised several elements. In the first place, late Victorian and Edwardian writers routinely insisted that doctors and teachers should start by educating the senses using various material apparatus (such as the peg-board, and size and form boards),14 and that “all teaching should be on the concrete system, as they are not capable, at least at first, of comprehending abstract ideas.”15 Only when the senses had been satisfactorily trained, were teachers to attempt scholastic instruction in reading, writing, and arithmetic.16 Secondly, medico-pedagogic theory emphasised the use of physical exercises to strengthen the body, to maintain physical health, and to develop and coordinate muscular movement. Physical training, sometimes referred to generically as “drill,” was ideally to take place in the open air, preferably accompanied by music, and was to proceed gradually from simple movements to more complex exercises.17 This emphasis on the educative value of physical exercise was by no means new, or indeed unusual, in this period. Drill had been introduced into elementary schools in the 1870s,18 and became increasingly important in the early twentieth century in the light of concerns about national fitness following the Boer War and in the wake of the report of the Interdepartmental Committee on Physical Deterioration in 1904.19 However, physical training was considered to offer particular benefits for the management of the feebleminded. Suitable exercise was thought not only to increase bodily health but also to encourage obedience, to remedy defective attention, and to stimulate the feebleminded “to use their limbs for useful purposes.”20 Finally, advocates of medico-pedagogy maintained that, in the case of the feebleminded, the “brain may often be got at by the avenue of the fingers more readily than by the accustomed route,”21 a notion that demanded careful attention to manual, rather than scholastic, instruction in special schools and classes. The need to amend the elementary school curriculum to suit the capabilities of the feebleminded became a familiar theme amongst educationalists. In the 1890s, Dr. George Shuttleworth (1842–1928) provided the Departmental Committee on Defective and Epileptic Children (of which he was a member) with a memorandum detailing how methods of instruction needed to be modified to take into account the physical defects of feebleminded children.22 During parliamentary debates on the Elementary Education (Defective and Epileptic Children) Bill in 1899, the Duke of Devonshire proposed that special grants from the Department of Education should only be made available if special classes offered a “proper portion of manual instruction, which those conversant with this question believe to be particularly beneficial in their case.”23 Some years later, Dr. Alfred Eicholz (1869–1933), who later became an inspector of special schools, pointed out that since admission to a

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special school was precipitated by an “inability to learn in the public elementary school,” it was “unwise to push on with him on public elementary school lines.”24 Dr. George Newman (1870–1948), Chief Medical Officer to the Board of Education and later Chief Medical Officer to the Ministry of Health, reiterated this point in his annual reports. In 1909, for example, he complained that “too much stress was being laid on the elementary subjects, and that insufficient opportunity was being given to manual occupations suited as regards nature and scope to the needs of the feeble-minded.”25 Accordingly, Newman and his colleagues at the Board of Education set guidelines for teachers and doctors involved in special education. In particular, they advised dividing manual instruction (of which there should be at least six hours each week) into three separate classes: lessons for younger children of both sexes, including instruction in dressing, washing, and tidiness, as well as knitting, clay-modelling, colour work, bead-threading, and basket- and mat-making; lessons in woodwork, shoe-making, modelling, tailoring, and garden and farm work for older boys; and lessons in cookery, laundry work, practical housewifery, and needlework for older girls.26 Within this framework, the passage from a class for younger children to one for older children was to be governed by ability rather than by age.27 Crucially, the perceived advantages of manual instruction went well beyond merely educational benefits for the feebleminded. Although manual work served to arouse intelligence and to improve “the higher faculties of memory, volition, and initiative,”28 it also carried administrative, disciplinary, and economic advantages. Manual or industrial training apparently not only improved the morale of feebleminded children,29 but also rendered them more amenable to discipline and prepared them for “a life of usefulness.”30 “Industrial and technical training,” wrote Alfred Tredgold in 1908, “is at once an educational factor of considerable importance, as well as the only means of turning these unfortunate children to practical account. It has been shown that, as a result of this training, a considerable number of the milder aments become capable of remunerative work.”31 These emergent educational principles are evident in the timetables of special classes, schools, and colonies from the late nineteenth and early twentieth centuries. The surviving tables of lessons from the Clapton School in the 1870s, from a special school in London, and from the Sandlebridge Boarding Schools run by Mary Dendy demonstrate a number of shared features: lessons that were often shorter (usually twenty minutes) than those in their ordinary elementary counterparts (which were usually of forty-five minutes duration); regular physical exercise, including drill and marching; and a liberal amount of manual training, often in simple domestic tasks and sometimes incorporating specific apparatus for educating the senses.32 Significantly, these timetables also demonstrate an apparent shift across time. Pupils at Clapton in the 1870s followed a fairly complicated timetable

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that covered not only a variety of manual tasks but also more complicated scholastic work, such as mental arithmetic, dictation and transcription, bible lessons, and natural history. By the turn of the century, however, in line with mounting pressure to fit such children for permanent retention in working colonies, special school timetables had become simplified. As Patricia Potts has suggested, there was a clear move away from desk-bound work: many of the scholastic studies had been discarded and pupils were increasingly occupied in mundane domestic chores.33 At Sandlebridge, for example, where time was meticulously managed from dawn until dusk, morning lessons focused on “head-work,” while the afternoon was devoted to “hand-work.”34 After morning prayers had been completed and the registers taken, lessons included reading, articulation and speech training, arithmetic, spelling, and nature. Although Mary Dendy expressed reservations about teaching the feebleminded to write, in case it allowed the men and women to communicate “with each other by means of notes,” the children at Sandlebridge did receive writing lessons.35 In addition, from 1910, a novel scheme for training the senses, using wooden models constructed by the colony’s manual instructor, provided a useful “variation from the usual lessons.”36 Morning lessons were interspersed with periods of recreation and with physical exercises, marching, singing, and ball games.37 After lunch, children attended lessons in manual occupations, including folding clothes, needlework and knitting, cleaning, gardening, rug-making, clay-modelling, drawing, and mat-weaving.38 From 1905, the older boys also received instruction in woodwork on Saturday afternoons. Crucially, manual training of this nature was carefully tailored to the work that young adults were expected to perform on graduating to the colony. On leaving the school at Sandlebridge, young men were employed under supervision on the farm, in the gardens and greenhouses, in the workshops with the plumber, joiner, and cobbler, or indoors doing housework. By contrast, young women generally worked in the kitchens, in domestic chores, and in the laundry and sewing rooms. In practical terms, and in line with Tredgold’s candid assessment of the value of industrial and technical training, these occupations contributed significantly to the colony’s financial position and, ultimately therefore, to its survival deep into the twentieth century. In this way, institutions such as Sandlebridge were thought to reduce the economic dependency of mental defectives on both state and charitable support.

The International Roots of British Medico-Pedagogy British doctors and educationalists formulating and implementing the principles of medico-pedagogy in special schools and classes at the turn of the nineteenth century were inspired and influenced both by conditions

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in England and by developments abroad. From a domestic perspective, Edwardian preoccupations with manual and industrial training for the feebleminded were prompted in part by a general trend toward a more liberal elementary school curriculum in the late nineteenth and early twentieth centuries. This trend was marked by an increase in the range of subjects for which government grants could be obtained and by efforts to make education “less bookish and more practical” in order to bring the child’s life in school “into closer relation with his life out of school.”39 Attempts to tailor education more closely to the “natural” developmental needs of children in this way may have been inspired in part by growing scientific interest in the child as an object of scientific study and by contemporary interest in tabulating the normal stages of infancy and childhood, both of which drew on Victorian preoccupations with evolution and progress.40 At the same time, contemporary emphases on manual work reflected an increasingly narrow and pessimistic view of the educational and social potential of children and adults identified as mentally defective, as well as growing concerns about productivity and national efficiency. By the first decade of the twentieth century, confidence in the restorative value of education was clearly fading. While doctors increasingly stressed the impossibility of instilling intelligence in the feeble mind,41 surveys of special school leavers suggested that very few feebleminded children proved capable of becoming self-supporting in adult life. In a climate dominated by anxieties about the financial burden of the social residuum, productive labor (regarded by the Charity Organisation Society as “the great discipline of life”) would enable the weak-minded to gain happiness and self-respect and, more important, by contributing to their maintenance, allow them to take their place in society.42 Significantly, by providing opportunities for industrial work under favorable circumstances, and by generating the means whereby the feebleminded could be brought to “their greatest industrial value,”43 rural residential schools and colonies such as Sandlebridge apparently constituted an exemplary route both to the reclamation of the feebleminded and to the regeneration of the race. Although Edwardian approaches to mental deficiency were clearly driven by a number of prominent national debates, a variety of wider historical and geographical factors also influenced the shape and direction of British medico-pedagogy. In the first place, the adoption of physiological and developmental approaches to education around the turn of the century represented a continuation of the moral treatment of insanity, which had first emerged in France but which had fuelled the aspirations of the English founders of idiot asylums to “educate the idiot.”44 It is no coincidence that, in the Edwardian period, the most forceful support for educating the feebleminded came from an older generation of doctors with extensive experience in charitable and municipal training institutions for idiots and imbeciles: George Shuttleworth,

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medical superintendent at the Royal Albert Asylum between 1870 and 1893; and Dr. Fletcher Beach (1845–1929), medical superintendent at the Darenth Asylum between 1878 and 1896 and later president of the Royal MedicoPsychological Association. Beach and Shuttleworth, and indeed many of their contemporaries, were also strongly inspired by the work of Dr. Edouard Séguin (1812–1880). In the middle decades of the nineteenth century, Séguin, who had studied under prominent French alienists and proponents of moral treatment such as Jean-Etienne Dominique Esquirol (1772–1840) and Jean Marc Gaspard Itard (1774–1838), had founded classes for mentally defective children in Paris and had elaborated a pedagogic system in which “physiological education” of the senses and the muscular system preceded, and indeed promoted, the development of mental and moral faculties.45 Séguin’s writings, particularly his Traitement moral, hygiène et éducation des idiots, first published in 1846, had a major impact both in America, where he settled after 1850, and in England, where his work provided not only the theoretical basis for medico-pedagogic approaches to mental deficiency but also the inspiration for Margaret McMillan’s restorative educational program for working-class children.46 Although Carolyn Steedman has suggested that “Séguin’s theories entered British educational thinking via Montessori’s work, rather than Macmillan’s,”47 it is clear that Séguin’s approach was well-known to British mental deficiency experts many years before Montessori’s methods became fashionable during the second and third decades of the twentieth century. Shuttleworth and Beach had met Séguin during a visit to America in 1876, and Shuttleworth and his coauthor, Dr. William Potts, subsequently dedicated their textbook on mentally defective children to the French physician, claiming that his work was to be regarded as “the magna charta of the mental emancipation of the imbecile class.”48 In addition to applauding the pioneering work of Séguin, British educationalists also exploited the seminal contributions of one of his contemporaries, Friedrich Froebel (1782–1852), a German teacher who had developed his own system of education after becoming convinced that the teaching techniques promoted by the Swiss educational reformer Johann Heinrich Pestallozzi (1746–1827) contained “far too much positive instruction.”49 Froebel’s philosophy, which he implemented first in his school at Keilhau and subsequently in the “kindergartens” for young children that he established in Germany in the 1840s, revolved around a number of key concepts that held clear resonance with later pedagogic approaches to the feebleminded: the importance of “learning by doing,” the educative value of play, the significance of following nature in order to ensure a child’s harmonious development, and the role of manual, as well as scholastic, work.50 Froebel’s impact on British attempts to educate both young and feebleminded children was immense. Shortly after kindergartens had been

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prohibited in Germany in 1851, the movement gathered momentum in England, partly as a result of the influx of German immigrants following the 1848 revolution. The first English kindergarten was opened in Hampstead in 1854, and the first society was established in Manchester some years later. In 1887, the Manchester Kindergarten Association joined forces with the Froebel Society of London (which had been founded in 1874) to form the National Froebel Union, which became the examining body for kindergarten teachers. Subsequently, the kindergarten concept became increasingly popular, resonating with parallel emphases on teachers as gardeners who were responsible for encouraging children to grow.51 The kindergarten system of education was immediately adopted and promoted by those involved in training mental defectives. The therapeutic and educational value of kindergarten toys and exercises for the feebleminded were forcefully advertised, for example, by P. Martin Duncan and William Millard (consulting surgeon and superintendent, respectively, at the Eastern Counties Asylum) in their manual for training defective children published in the 1860s, by the Charity Organisation Society in the 1890s, and by Alfred Tredgold and George Shuttleworth and William Potts in the early twentieth century.52 In addition, not only did the Board of Education increasingly advocate the use of kindergarten occupations and manual instruction in ordinary elementary schools from the 1890s,53 but it also insisted that principal and assistant teachers in special schools should hold the certificate of either the Board of Education or the National Froebel Union.54 Although the Board expressed some concerns about the use of overly structured and “artificial and unreal” kindergarten games,55 and although Mary Dendy and Shuttleworth and Potts recommended modifying the kindergarten approach for use in British special classes and schools,56 Froebel’s methods remained influential at both national and local levels. In Manchester, for example, the superintendent of special schools, Jane B. Dickens, was “both an enthusiast and an authority” in the use of Froebel’s kindergarten techniques.57 The Reverend S. Alfred Steinthal, Unitarian minister at Cross Street Chapel in Manchester, a friend of Mary Dendy and a member of the Lancashire and Cheshire Society for the Permanent Care of the Feeble-Minded, was also renowned for being in favor of Froebel’s approach,58 and the principal and teachers at Harpurhey Hall Special School in Manchester held Froebel certificates.59 In addition to drawing on the work of particular pioneering educationalists such as Séguin and Froebel, British advocates of medico-pedagogic approaches to the feebleminded were also strongly influenced by broader practical developments in both European and North American institutions. In the first place, early British initiatives were motivated and shaped by knowledge of the “auxiliary” or “intermediate” schools that were being established particularly in Germany during the last quarter of the nineteenth century.60 Such schools, the first of which was opened in Dresden

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in 1860, were expressly designed for backward children who were not progressing at ordinary schools. During the 1880s, British commentators, who had either heard about auxiliary schools from correspondents or who had sometimes visited the schools themselves, increasingly lamented the “important hiatus in our English education system” exposed by the rapid spread of special schools in Germany and Norway.61 Although commentators were not always uncritical of such schools, insisting that in many cases residential institutions carried the added benefit of removing the child from an unsavoury home environment and expressing concerns about the cost of special education, they nevertheless applauded continental commitments to this form of education. “With such practical Teutonic and Scandinavian precedents,” reported Shuttleworth in 1888, “there would seem ample encouragement for the movement in favour of schools for ‘intermediate cases of mental feebleness’ in London and other large towns.” More critically, he also suggested that “surely what a poor country like Norway can do wealthy England can afford.”62 The colony system that emerged in Germany and Belgium for the management of idiots, imbeciles, and epileptics also captured the imagination of British commentators eager to devise and refine novel schemes for housing mental defectives. In 1897, for example, Dr. John Milson Rhodes (1847–1909), a doctor and prominent Poor Law Guardian from Manchester, and a colleague from the Chorlton and Manchester Joint Asylum Committee were appointed by the Committee to visit a number of institutions for treating imbeciles and epileptics in Germany, France, and Belgium. On their return, they published an account of the asylums visited and suggested that imbeciles and epileptics should be housed in either pavilions or colonies similar to those observed abroad.63 Rhodes in particular became an ardent advocate of colonies built “on the models of those in Germany.”64 Although Rhodes’s plans for special provisions in Manchester and his critique of certain English institutions (particularly the colony for epileptics at Chalfont) provoked continued debate in the columns of the British Medical Journal,65 he was not alone in drawing on German precedents. Several years later, Alfred Eicholz similarly advocated adopting the colony solution that he had witnessed first-hand at Ursberg in Bavaria.66 Significantly, while European institutions sometimes provided blueprints for British reformers such as Rhodes and Eicholz, British institutions operated in a similar fashion for international visitors: Sandlebridge, for example, was regularly visited by travellers from Europe, North America, and Australasia who were eager to learn about Dendy’s methods.67 In addition to their knowledge of, and support for, the methods and approaches enforced in European institutions, many leading commentators on the care of the feebleminded in Britain were also well acquainted with educational and custodial arrangements in the large American training

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schools and asylums, such as those run by Samuel Gridley Howe and Hervey Wilbur in Massachusetts and New York, by Isaac Kerlin in Pennsylvania, and by Walter Fernald in Waverley, Massachusetts.68 British doctors often visited these American pioneers, most of whom had self-consciously fashioned the construction and management of their institutions around Séguin’s notion of “physiological education.” In 1876, for example, George Shuttleworth and Fletcher Beach visited nine specialist American institutions for training the feebleminded and published a detailed account of their findings.69 Over the next few decades, British authors regularly applauded American efforts in this field and, in 1905, five members of the Royal Commission on the Care and Control of the Feeble-Minded embarked on an extensive tour of thirty-nine American institutions in order to gather information that might prove useful to the British legislature. In the first decade of the twentieth century, Mary Dendy, perhaps the most influential champion of Edwardian plans to segregate the feebleminded in purpose-built institutions that prioritized manual training for work in a residential colony, also corresponded with and visited the superintendents of American institutions. In particular, Dendy was impressed by Walter Fernald’s colonies at Waverley and Templeton, suggesting that Fernald’s methods “worked exactly on our Sandlebridge lines, and we agree at every point.”70 The effective translation of American ideas into Britain is evident at the Sandlebridge Boarding Schools: although manual instruction had been formally introduced to the curriculum at Sandlebridge in 1904, the creation of a “new scheme for training the special senses” in 1910 was clearly a direct product of Mary Dendy’s visit to Fernald the previous year.71 In addition to providing inspiration for medico-pedagogic approaches to educating the feebleminded, international educational models also pricked the pride of British reformers who were anxious that Britain’s educational policies, like her imperial and military strength, were slipping behind those of her commercial and military competitors. In 1865, Cheyne Brady applauded American, German, and Danish legislatures in particular for recognizing that the care and education of imbeciles constituted a “public duty,” and questioned when “the hard reasoning of our political economists” would be similarly “leavened with true wisdom.”72 Similarly, having pointed to examples of developments in Germany and Norway, in 1888 Shuttleworth asked whether it was not “the duty of a professedly Christian nation, even in relation to our educational systems, to ‘gather up the fragments that remain that nothing be lost?’”73 John Milson Rhodes was characteristically more forthright. In a speech to the North-Western Poor-Law Conference in 1898, in which he set out his observations on the German system, Rhodes pointed out “that the public institutions of a country were the standard of its civilisation, and that England must not lag behind America and Germany in its provision for the epileptic and feeble-minded class.”74 As these quotes

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demonstrate, late Victorian and Edwardian reformers exploited their knowledge of a wide geographical range of educational approaches in order to construct their own brand of British medico-pedagogy.

Conclusion It is tempting to understand British formulations of medico-pedagogy entirely in terms of growing domestic concerns about the social problems associated with an apparently rising tide of degenerates and delinquents: the insane, the feebleminded, moral imbeciles, the epileptic, and so on. While it is clearly true that British preoccupations with manual training, with educating the mind through the body, and with fitting the feebleminded for life in a working colony were shaped by anxieties about the limited social capabilities of mental defectives and by concerns about productivity and national efficiency, British reformers such as George Shuttleworth, Mary Dendy and Alfred Tredgold (and indeed the government) also looked abroad for inspiration and example, regularly exploiting opportunities to correspond with and visit the superintendents of a number of foreign institutions in both Europe and North America. However, it is unlikely that Maria Montessori’s educational initiatives in Rome proved to be a major influence on the emergence of medico-pedagogic methods, as both Pritchard and Steedman have suggested. There were, of course, clear similarities between medico-pedagogy in England and the philosophy and methods devised by Montessori in Italy. In particular, Montessori’s reliance on Séguin, and her emphasis on development, on educating the senses and exercising the body, and on the role of work in a prepared environment, were comparable to principles adopted in England. However, not only did British approaches to special education mature in the last decades of the nineteenth century, well before Montessori’s writings became popular, but British educationalists also harboured doubts about her approach. Thus, although some medical writers were clearly impressed by Montessori’s ideas,75 the Board of Education, as well as individual doctors and teachers, continued to express reservations about wholesale adoption of the Montessori method and doubted whether Montessori offered any advantages over Séguin.76 Instead, as I have suggested here, British advocates of medico-pedagogy exploited the permeability of national boundaries in this period and looked to ideological and practical developments in France, Germany, Scandinavia, and America. Drawing heavily on the principles set out by Séguin and Froebel in the middle decades of the nineteenth century, British doctors and teachers working in asylums and special schools adapted the techniques that they had witnessed in continental European auxiliary

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schools and in custodial institutions and colonies that they had visited in America and Europe for use in their own institutions. The adoption of novel international approaches in order to solve domestic social problems of this nature was not limited to strategies to managing the feebleminded. As Sarah Hayes has argued in her study of maladjustment, British pioneers of progressive education for juvenile delinquents also looked abroad for inspiration. In 1907, the American teacher Homer Lane (1875–1925) opened the Ford Republic for delinquent boys as a novel form of education for children displaying challenging behavior. Lane’s vision was based heavily on the Sloyd Movement, an approach to education that emphasised the attainment of practical, rather than academic, skills and that had been initiated in Finland by Uno Cygnaeus (1810–88). Lane’s approach at the Ford Republic subsequently inspired the British penal reformer George Montagu (1874–1962) to found a similar institution in Britain, the Little Commonwealth, in 1913 with Lane in charge.77 As the development of both medico-pedagogic approaches to feeblemindedness and progressive educational approaches to juvenile delinquency suggest, it is more constructive and accurate to regard British medico-pedagogy not primarily as the result of growing interest in Montessori’s methods but as the product of a broader European tradition of physiological education that was first formulated by Séguin and Froebel and subsequently amended by reformers throughout Europe and North America. First instituted in special schools and asylums particularly in Germany and America, physiological education was subsequently adapted by British doctors and educationalists to fit a particular national social and political context.

Notes I would like to thank the Wellcome Trust for funding the research on which this work is based. 1. D. G. Pritchard, Special Education and the Handicapped 1760–1960 (London: Routledge, 1963), 181. 2. Carolyn Steedman, “Bodies, Figures and Physiology: Margaret McMillan and the Late Nineteenth-Century Remaking of Working-Class Childhood,” in In the Name of the Child: Health and Welfare, 1880–1940, ed. Roger Cooter (London: Routledge, 1992), 19–44. 3. Maria Montessori, The Montessori Method: Scientific Pedagogy as Applied to Child Education (London: Heinemann, 1912). 4. On Montessori and her methods, see E. M. Standing, Maria Montessori: Her Life and Work (London: Hollis and Carter, 1957); Rita Kramer, Maria Montessori: A Biography (Oxford: Basil Blackwell, 1976). 5. James W. Trent, Inventing the Feeble Mind: A History of Mental Retardation in the United States (Berkeley: University of California Press, 1994); Mathew Thomson, The

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Problem of Mental Deficiency: Eugenics, Democracy, and Social Policy in Britain, c. 1870– 1959 (Oxford: Clarendon Press, 1998); Mark Jackson, The Borderland of Imbecility: Medicine, Society, and the Fabrication of the Feeble Mind in Late Victorian and Edwardian England (Manchester: Manchester University Press, 2000). 6. During the late nineteenth and early twentieth centuries, the terms idiot, imbecile, and feebleminded were used to denote varying degrees of intellectual impairment, increasingly referred to collectively as mental deficiency. The terms are used in this paper with these contemporary meanings in mind. 7. For more on the idiot asylums, see David Wright, Mental Disability in Victorian England: The Earlswood Asylum 1847–1901 (Oxford: Clarendon Press, 2001); David Gladstone, “The Changing Dynamic of Institutional Care: The Western Counties Idiot Asylum, 1864–1914,” in From Idiocy to Mental Deficiency: Historical Perspectives on People with Learning Disabilities, ed. David Wright and Anne Digby (London: Routledge, 1996), 134–60. 8. David S. Stewart, “Paved with Good Intentions: The Hampstead and Clapton Schools, 1873–1878,” British Journal of Learning Disabilities 28 (2000): 54–59. 9. Thomson, The Problem of Mental Deficiency; Jackson, The Borderland of Imbecility. 10. See the discussion in Jackson, The Borderland of Imbecility. 11. G. E. Shuttleworth, “Mental Deficiency,” in Encyclopaedia Medica, vol. 8, ed. Chalmers Watson (Edinburgh: William Green and Sons, 1901), 39. See also C. J. Thomas, “Motor Training in Elementary Schools,” Journal of State Medicine 18 (1910): 156–59; John Arrowsmith, “Medico-Pedagogic Methods in Primary School Education,” Journal of State Medicine 22 (1914): 430–34. 12. G. E. Shuttleworth, “On the Treatment of Children Mentally Deficient,” Union of Teachers of the Deaf on the Pure Oral System: Transactions of the Society, no. 2 (12 December 1895): 6. 13. See, for example, A. F. Tredgold, Mental Deficiency (Amentia) (London: Baillière, Tindall and Cox, 1908), 333. 14. For an account of these, see G. E. Shuttleworth and W. A. Potts, Mentally Deficient Children: Their Treatment and Training, 4th ed. (London: H. K. Lewis, 1916), 189–96. 15. Fletcher Beach, “Education of the Mind,” Encyclopaedia Medica, vol. 8, 114. See also Tredgold, Mental Deficiency, 341–44. 16. Fletcher Beach, The Treatment and Education of Mentally Feeble Children (London: J. & A. Churchill, 1895), 28–29. 17. See Shuttleworth, “On the Treatment of Children Mentally Deficient,” 11; J. Lougheed Baskin, “Treatment of the Neurasthenic States and Mental Disease by Physical Exercises,” Journal of State Medicine 13 (1905): 92–98; Tredgold, Mental Deficiency, 344–47; Archibald R. Douglas, “The Care and Training of the Feeble-minded,” Journal of Mental Science 56 (1910): 253–61; M. H. Royle, “Mental Defectives and Physical Education in the Special Schools,” Journal of the Incorporated Society of Trained Masseuses (1917): 133–36. 18. Report of the Board of Education 1910–1911 (Cd. 6116, London), 9. 19. For a discussion of the committee’s report and the role of physical education, see Richard Soloway, “Counting the Degenerates: The Statistics of Race Deterioration in Edwardian England,” Journal of Contemporary History 17 (1982): 137–64; Richard A. Soloway, Demography and Degeneration: Eugenics and the Declining

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Birthrate in Twentieth-Century Britain (Chapel Hill: University of North Carolina Press, 1990), 43–47; Bernard Harris, The Health of the Schoolchild: A History of the School Medical Service in England and Wales (Buckingham: Open University Press, 1995), 6–25; John Welshman, “Physical Culture and Sport in Schools in England and Wales, 1900–1940,” International Journal of the History of Sport 15 (1998): 54–75. 20. Baskin, “Treatment of the Neurasthenic States,” 98. See also Shuttleworth, “On the Treatment of Children Mentally Deficient,” 11; Shuttleworth and Potts, Mentally Deficient Children, 202. 21. G. E. Shuttleworth, “Idiots and Mentally Deficient Children,” Medical Annual (1897): 303. See also Shuttleworth’s comments following Eicholz’s presentation in British Medical Journal (6 September 1902): 687; Francis Warner, “Training of the Feeble-minded,” The Lancet (26 March 1904): 864–65; and Tredgold’s assertion that it “is a well-recognized fact that the mentally deficient child learns more with his hands than with his head,” Tredgold, Mental Deficiency, 351. 22. Report of the Departmental Committee on Defective and Epileptic Children (C. 8746, London, 1898), 39–40. 23. Parliamentary Debates (1899), 73, col. 396. 24. A. Eicholz, “The Treatment of Feeble-minded Children,” British Medical Journal (6 September 1902): 683–87, 685. The need to move from scholastic to manual instruction was also stressed in the Report of the Royal Commission on the Care and Control of the Feeble-Minded, vol. 8 (Cd. 4202, London, 1908), 103–12, 159. 25. Annual Report of the Chief Medical Officer of the Board of Education, 1909, 158. 26. Report of the Departmental Committee on Defective and Epileptic Children (C. 8746, London, 1898), 18–21; Report of the Board of Education 1899–1900, vol. 3, 785, 790; Report of the Board of Education 1901–1902 (Cd. 1275, London, 1902), 38–39; Annual Report of the Chief Medical Officer of the Board of Education, 1909, 159–60; Shuttleworth and Potts, Mentally Deficient Children, 213–15. 27. Report of the Departmental Committee on Defective and Epileptic Children, 19; Report of the Board of Education 1899–1900, vol. 3, 785. 28. Eicholz, “The Treatment of Feeble-minded Children,” 685. See also Shuttleworth, “Idiots and Mentally Deficient Children,” 303; Warner, “Training of the Feeble-minded,” 864–65. 29. According to the Board of Education, manual work made defectives “feel less of ‘anti-socials’ for the contribution of something useful as the result of their efforts,” Report of the Board of Education 1901–1902, 39. 30. See: Annual Report of the Chief Medical Officer of the Board of Education 1909, 161; Mary Dendy, “Feeble-minded Children,” Journal of State Medicine 22 (1914): 412– 18, 412. 31. Tredgold, Mental Deficiency, 351–52. See also James Kerr’s later opinion that industrial training could “make the child an efficient citizen, self-supporting and self-respecting,” quoted in Patricia Potts, “Medicine, Morals, and Mental Deficiency: The Contribution of Doctors to the Development of Special Education in England,” Oxford Review of Education 9 (1983): 181–96. 32. The timetable from Clapton was kindly provided by David Stewart. Timetables from the London special school and Sandlebridge are reproduced in Potts, “Medicine, Morals, and Mental Deficiency.”

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33. See Potts, “Medicine, Morals, and Mental Deficiency.” 34. The terms used in the Annual Report of the Lancashire and Cheshire Society for the Permanent Care of the Feeble-Minded (1913): 17. 35. Mary Dendy, “On the Training and Management of the Feeble-minded,” in Feeblemindedness in Children of School Age, ed. Charles P. Lapage (Manchester: Manchester University Press, 1911), 276; Mary Dendy, “The Care of the Feeble-minded,” in Proceedings at a Conference on the Care of the Feeble-Minded, Manchester and Salford Sanitary Association (London: Sherratt and Hughes, 1911), 43–61; Cheshire Record Office (CRO) NHM 11/3837/44, 51. 36. Annual Report of the Lancashire and Cheshire Society (1910), 12, 14; Annual Report of the Lancashire and Cheshire Society (1912), 12; CRO NHM 11/3837/44, 223. 37. Potts, “Medicine, Morals, and Mental Deficiency,” 193. On the value of games to increase coordination, see Annual Report (1912), 12. 38. For references to a range of manual occupations, see CRO NHM 11/3837/44, 11, 18; Annual Report (1912), 12. See also Potts, “Medicine, Morals, and Mental Deficiency,” 194. 39. Report of the Board of Education 1910–1911, 6–23, 40. 40. See Lyubov Gennadyevna Gurjeva, Everyday Bourgeois Science: The Scientific Management of Children in Britain, 1880–1914 (PhD diss., Cambridge, 1998). 41. Tredgold, Mental Deficiency, 339, 347. See also the comment that “no system of education can transmute these children into normal full-powered adults” in a review of Shuttleworth and Potts’s book in the Medical Officer 4 (1910); 91. 42. Charity Organisation Society, On the Education and Care of Idiots, Imbeciles, and Harmless Lunatics (London: Longmans, Green and Co., 1877), 8, 11–13. 43. Dendy, “The Care of the Feeble-minded,” 47. 44. On the educational aspirations of the idiot asylums, see also Gladstone, “The Changing Dynamic of Institutional Care”; Michael Anthony Barrett, From Education to Segregation: An Inquiry into the Changing Character of Special Provision for the Retarded in England, c. 1846–1918 (PhD diss., Lancaster, 1986). 45. On Séguin’s theories and influence, see Steedman, “Bodies, Figures and Physiology,” 19–44; Trent, Inventing the Feeble Mind, 40–59. 46. See Trent, ibid.; Steedman, ibid.; Carolyn Steedman, Childhood, Culture and Class in Britain: Margaret McMillan, 1860–1931 (London: Virago, 1990). 47. Steedman, “Bodies, Figures and Physiology,” 27. 48. Shuttleworth and Potts, Mentally Deficient Children, 2–3. For further contemporary references to Séguin, see Charles West, Lectures on the Diseases of Infancy and Childhood (London: Longmans, Green and Co., 1884), 288–89; Walter Fernald, The History of the Treatment of the Feeble-Minded (Boston: Geo. H. Ellis, 1893), 3–4; Shuttleworth, “On the Treatment of Children Mentally Deficient,” 1–2, 6–7; The Lancet (11 August 1900): 407; Tredgold, Mental Deficiency, 336. 49. Friedrich Froebel, Autobiography of Friedrich Froebel (London: Swan Sonnenschein and Co., 1908), 55. 50. The evolution of his philosophy is explained in Froebel, Autobiography of Friedrich Froebel, passim. See also Peter Weston, Friedrich Froebel: His Life, Times, and Significance (London: University of Surrey Roehampton, 2000). 51. Froebel, “Chronological Abstract of the Principal Events in the Life of Froebel and the Kindergarten Movement,” in Autobiography of Friedrich Froebel, 163–68. See

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also Evelyn Lawrence, Friedrich Froebel and English Education (London: University of London Press, 1952); Sarah Hayes, The Medicalisation of Maladjustment: The Conceptualisation and Management of Child Behavioural Problems in Britain, ca. 1890–1955 (PhD diss., University of Exeter, 2008). 52. P. Martin Duncan and William Millard, A Manual for the Classification, Training, and Education of the Feeble-Minded, Imbecile, and Idiotic (London: Longmans, Green and Co., 1866), 138; Charity Organisation Society, The Feeble-Minded Child and Adult (London: Swan Sonnenschein and Co., 1893), 59–67, 74; Tredgold, Mental Deficiency, 336; Shuttleworth and Potts, Mentally Deficient Children, 187. 53. See the comments in Report of the Board of Education 1899–1900, vol. 3 (Cd. 330, London, 1900), 691; Report of the Board of Education 1910–1911 (Cd. 6116, London, 1912), 17, suggesting that the principles of Froebel were first officially recognized by the Department of Education in 1893. 54. Report of the Board of Education 1899–1900, 784. According to Henry Ashby, the need for a principal teacher to be certificated was abolished by the Board of Education in 1906/7, City of Manchester Education Committee Annual Report 1906–7, 97, Local Studies Unit, Central Library, Manchester, 379.1 M3. 55. Report of the Board of Education 1913–1914 (Cd. 7934, London, 1915), 226. 56. Dendy, “On the Training and Management of Feeble-minded Children,” 274; Shuttleworth and Potts, Mentally Deficient Children, 187. 57. “Miss Jane B. Dickens,” Manchester Faces and Places 13 (August 1902): 209–11. 58. See Manchester Faces and Places 3 (1892): 149–50. 59. See material in the Public Record Office (PRO) ED 32/60. 60. For references to German and other European systems, see “Weak-minded Children,” Journal of Mental Science 34 (1888): 80–88; Charity Organisation Society, The Feeble-minded Child and Adult, 68–71; J. M. Rhodes and A. McDougall, Treatment of Imbeciles and Epileptics: Report to the Chorlton and Manchester Joint Asylum Committee, on the Best Methods for the Care and Treatment of Imbeciles and Epileptics (Manchester, 1897); Alfred Eicholz, “The Treatment of Feeble-minded Children,” British Medical Journal (6 September 1902): 686; Annual Report of the Chief Medical Officer of the Board of Education 1909 (Cd. 5426, London, 1910), 162; Annual Report of the Chief Medical Officer of the Board of Education 1910 (Cd. 5925, London, 1911), 212; Ettie Sayer, “Mentally Defective Children and Their Treatment,” Journal of State Medicine 22 (1914): 152–62; Shuttleworth and Potts, Mentally Deficient Children, 35–50. 61. “Weak-minded Children,” 80. 62. Ibid., 83–84. See also the notes on Norwegian schools supplied by Dr. W. W. Ireland in ibid., 84–88. 63. Rhodes and McDougall, Treatment of Imbeciles and Epileptics. 64. See British Medical Journal (1 October 1898): 996. On Rhodes, see Jean Barclay, “John Milson Rhodes, 1847–1909: Chorlton Guardian and Didsbury Doctor,” Manchester Region History Review 6 (1992): 107–12. 65. See the correspondence in the British Medical Journal (15 October 1898), 1197; (29 October 1898), 1374; (12 November 1898), 1479, 1525. 66. Eicholz, “The Treatment of Feeble-minded Children,” 683–87. 67. CRO NHM 11/3837/19, Warford Hall Visitors Book. For further details, see Jackson, The Borderland of Imbecility, 72–74. 68. See Trent, Inventing the Feeble Mind.

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69. G. E. Shuttleworth, Notes of a Visit to American Institutions for Idiots and Imbeciles (no publisher, n. d.). 70. Quoted in H. McLachlan, Records of a Family 1800–1933: Pioneers in Education, Social Service and Liberal Religion (Manchester: Manchester University Press, 1935), 170. 71. Annual Report of the Lancashire and Cheshire Society (1910), 14, 12, illustration facing p. 12. For details of her visit, see McLachlan, Records of a Family, 155–58, 169– 70. Mary Dendy gave extensive accounts of Fernald’s approach to the education and training of mental defectives: Dendy, “On the Training and Management of Feebleminded Children,” 271–74; Dendy, “The Care of the Feeble-minded,” 55–60; Dendy, “Feeble-minded Children,” Journal of State Medicine 22 (1914): 412–18. 72. Cheyne Brady, The Training of Idiotic and Feeble-Minded Children (Dublin: Hodges, Smith and Co., 1865), 15–17. 73. “Weak-minded children,” 84. 74. British Medical Journal (1 October 1898): 996. 75. Hamilton C. Marr, “The Mentally Defective Child,” Defective Children, ed. T. N. Kelynack (London: John Bale, Sons and Danielsson, 1915), 18, 28. 76. Report of the Board of Education 1913–1914, 227; Arrowsmith, “Medico-Pedagogic Methods,” 433; Shuttleworth and Potts, Mentally Deficient Children, 191–92. 77. Hayes, The Medicalisation of Maladjustment, chap. 5.

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Chapter Three

Organizing Psychiatric Research in Munich (1903–1925) A Psychiatric Zoon Politicon between State Bureaucracy and American Philanthropy Eric J. Engstrom Introduction In the imaginations of many observers prior to World War I, the psychiatric clinic in Munich epitomized the professional ideals of psychiatric training and research. Inaugurated in 1904, it quickly gained a reputation as a model institution and became a shrine on the pilgrimage of numerous American and European psychiatrists in search of professional edification. The clinic’s reputation was derived in good part from the prestige of its first director, Emil Kraepelin (1856–1926). By the turn of the century, Kraepelin was fast becoming Germany’s foremost clinical psychiatrist, internationally renowned for his classification of endogenous psychoses. Kraepelin’s enormous influence on psychiatric classification has had a profound impact on his historical legacy.1 Advocates and detractors alike have been inclined to debate his significance above all within nosological parameters. The resulting historiography has shown a decided predilection for psychiatric concepts. Indeed, Kraepelin’s legacy has in some respects come to be held hostage to an historiographic preoccupation with the origins and implications of his psychiatric nosology. Deserved or not, the attention given to his classification of mental disorders has tended to eclipse other important facets of his work—facets that proved crucial to the profession’s development in the twentieth century and that are as pertinent to psychiatric research today as they were a century ago. This article looks beneath Kraepelin’s nosology to consider another aspect of his work that, if one purviews the literature, has rarely become the object of historical inquiry.

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I am speaking of what one can call the politics of psychiatric research. This article will focus not so much on the end products of research as presented and preserved in the form of canonized textbook knowledge, but rather on the far messier practices and strategies involved in the production of that knowledge. In other words, it shifts attention away from the history of ideas—away from disease concepts and textbook nosologies—toward the history of professional politics and suggest that we can profitably recast our historical narratives of psychiatry in just such terms. We should try to imagine a history of psychiatry in which Kraepelin’s relevance is grounded not just on his reputation as a grand taxonomist, but also on his labors as an organizer of psychiatric research and a professional political animal—or, if you will, as a psychiatric zoon politicon. This article will emphasize one important dimension of that political animal’s world: Kraepelin’s relations with the state. This is by no means a new trope. Historians have often emphasized his close relations to the state, some even going so far as to describe his work as “state psychiatry.”2 Indeed, there is no shortage of evidence in the historical record that can be cited in support of this claim: Kraepelin spent his entire career in the employ of state institutions, he defended the sociopolitical status quo by imputing biological legitimacy to the ruling Wilhelmine classes, and of course more generally, to the extent that psychiatry delivered “solutions” to the vexing problems surrounding madness, his psychiatry can be interpreted as stabilizing a wider body politic. As accurate as these observations are, their analytic grasp is limited when it comes to explaining Kraepelin’s understanding of the role of the state in organizing psychiatric research. His professional politics are rather poorly captured if understood simply in terms of their being the dumb instruments of state policy or of a putative “Ordnungspsychiatrie.”3 Instead, I will argue that his relations with state officials were decidedly ambiguous, due in good part to his experiences with public officials. As his interests shifted increasingly toward social policy issues after 1900, he found his entreaties to the state rebuffed on numerous occasions. Furthermore, the frustrations that arose out of his interaction with public officials represent an important backdrop to his growing interest in North American models of higher education and research funding after 1908. Kraepelin certainly did not turn away from or seek wholly to supplant the state’s role in psychiatric affairs, but his interest in American philanthropy is a reflection of his skepticism of the state’s ability to support adequately psychiatric research. I will consider Kraepelin’s career after the grand classificatory accomplishments of the 1890s. I will focus on his tenure at the clinic in Munich, i.e., on the advanced stages in his career during which his professional reputation in Germany and abroad was already well-established. These were certainly not the halcyon days of Kraepelin’s career; rather, they were days in which

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he acquired, within contemporary circles, a reputation as a scientific manager to rival his reputation as a clinical researcher.

The Psychiatric Tasks of the State Kraepelin’s departure from Heidelberg in 1903 was rooted in a long-standing disagreement between himself and state officials in Baden.4 The dispute revolved around the autonomy of the clinic, in particular around the rules governing admission and discharge. Those rules had hampered Kraepelin’s ability to collect patient information for his research. He found the interests of psychiatric science to be at odds with the state’s responsibility to provide psychiatric care facilities for the general population. At the end of his tenure in Heidelberg he had become so exasperated with the constraints placed on his research that he began advocating the wholesale disassociation of his clinic from the state system of psychiatric care.5 In other words, at the very location where he conducted his groundbreaking clinical research, he lived with conditions that he deemed antithetical to the fulfillment of the aims of that research. In 1900, Kraepelin’s concerns about the institutional and administrative configuration of psychiatric care in Baden and its effects on psychiatric research and training prompted him to publish his thoughts in Psychiatric Tasks of the State.6 In this book Kraepelin effectively reminded state officials of their psychiatric responsibilities. He claimed that psychiatric care was a matter of fundamental public concern because of the need both to protect the public from dangerous patients and to protect and care for people whose families could no longer cope with them. He furthermore insisted that the state retain and expand asylum-based care and warned against the dangers of privatizing psychiatric institutions. He believed that the state needed to implement effective measures to regulate hospital admission and discharge, safeguard patients’ rights, guarantee psychiatric training of state physicians, and ensure the effective supervision of asylums.7 He also believed that the state had the responsibility to support psychiatric research and that it should work to improve the career opportunities and financial standing of psychiatric professionals. What is so arresting about these demands is that they were so completely unspectacular. What Kraepelin called for in 1900 had long been standard dogma among psychiatric professionals. He was doing nothing more than reiterating the long-standing demands of his colleagues. It is significant that Kraepelin also envisioned the state as having an important prophylactic role to play in psychiatric affairs.8 Without elaborating on specific policy initiatives, he believed that the state had both the responsibility and the power to effect changes that would help reduce the causes of madness. He insisted that in the prevention of alcohol and

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substance abuse, as well as in the prevention of syphilitic infection, the state could reap important benefits through prophylactic intervention. These concerns about the social costs of alcoholism and syphilis drove Kraepelin increasingly into the social policy arena. A quick glance at his publications after 1900 show him paying greater attention to topics such as alcoholism, crime, degeneration, and hysteria.9 This shift in emphasis to public-policy issues was a reflection of numerous factors. For one, his research had impressed upon him and reinforced his own ideas about the effects of heredity and “degeneration” on the development of psychiatric disorders. In addition, his own career advancement shifted his attention away from primary clinical research and toward pronouncements on larger social issues. More locally, the Bavarian beer culture and the powerful political influence wielded by breweries spurred Kraepelin to speak out in public on these issues. And finally, at a more general level, he shared the broader bourgeois concerns of his era, including the uncertainties of mass society and deepening class divisions as embodied in the rise of organized labor and social democracy, to say nothing of the anxieties aroused by contemporary discourse on nervousness and hysteria. In terms of the content of these writings, we find Kraepelin advancing more substantial and explicit eugenic demands designed to preserve and enhance the health of the German populace, or the Volkskörper.10 While praising the “magnificent network of institutions”11 built to care for psychiatric patients, he nevertheless remained disappointed with the prophylactic achievements of the state. Indeed, for all of his passionate concern about the German Volkskörper, he was skeptical of the state’s ability to preserve and enhance it. There were two basic reasons for his skepticism: First, his own Darwinist convictions meant that the state was as likely to impede as to enhance the very processes of natural selection that he believed were crucial to strengthening the Volkskörper and ameliorating the scourge of madness. He feared and was antithetical to all state initiatives that might countermand the laws of nature. For example, while the state was certainly to be commended for its support of psychiatric institutions, its own social welfare policies and the comforts of modern civilization simultaneously exposed the general population to the dangers of “domestication” and “effeminization.” Kraepelin’s regard for the state was therefore decidedly ambiguous: on the one hand, he could applaud its achievement of institutionalizing psychiatric care; on the other hand, however, he was highly critical of policies that he believed threatened to exacerbate the forces of “degeneration” and interfere with the “natural self-purification of [the German] folk.”12 Second, Kraepelin’s expectations also evolved in response to his own direct experiences with the state. And these experiences were, in his eyes, not always salutary. It is therefore worthwhile to review some of them and reflect on their significance for his work as a research organizer.

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Organizing Psychiatric Research in Munich Many of the same difficulties that had threatened Kraepelin’s psychiatric research in Heidelberg also afflicted psychiatric administration in Bavaria prior to his arrival in 1903.13 Most significant, severe overcrowding had wreaked havoc on statutory regulations governing admission and discharge. As a result, from about the mid-1890s a rising crescendo of jurisdictional disputes, accidents on the wards, and public outcry in the press had prompted administrators and politicians to action. In its efforts to resolve these problems, the local county decided to build a new asylum outside of Munich, thus robbing the university of its psychiatric hospital. As a consequence, the University of Munich was forced into negotiations with the city magistrates—negotiations that ultimately resulted in the construction of a new university psychiatric clinic. Initial plans for the clinic had been drafted by Anton Bumm, but his sudden death saw Kraepelin called to Munich in 1903 to finish the work. In his negotiations with Bavarian officials, Kraepelin was determined to ensure that the difficulties he had encountered in Heidelberg did not repeat themselves in Munich. He succeeded in extracting concessions that gave him wide and unspecified jurisdiction over patient admissions and discharges. Indeed, in a measure unprecedented in German psychiatric institutions at that time, he insisted that the clinic be given no statutes whatsoever in order to assure its autonomy. It was not until a patient took Kraepelin to court in 1907 that Bavarian officials succeeded in imposing statutes on Kraepelin’s clinic.14 After arriving in Munich, Kraepelin undertook a number of steps to enhance the research environment in the new clinic.15 For example, he created the position of “research assistant” to accommodate colleagues temporarily in positions without pay.16 With the exception perhaps of Robert Gaupp, all of Kraepelin’s most important colleagues (Alois Alzheimer, Ernst Rüdin, Felix Plaut, and Max Isserlin) were beneficiaries at one time or another of this position. Kraepelin maintained that without these colleagues, it would have been impossible to conduct serious research in the clinic. In other words, the core group of research scientists working in the Munich clinic held positions in which the resources of the clinic were placed at their disposal, without drawing a salary from the institution itself. In the ensuing years, Kraepelin made every effort to ensure that the anatomical, chemical, and serological laboratories used by these researchers were so generously funded as to be the “first and best in the world.”17 Kraepelin also organized an exchange program with local asylums in Eglfing and later in Haar and Gabersee.18 The arrangement saw young doctors in the respective institutions switching positions for a period of three months. The program was part of Kraepelin’s ongoing interest in maintaining cordial relations with his alienist colleagues. Speaking at the regional

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conference of Bavarian psychiatrists shortly after his arrival, he had appealed to alienists for their cooperation in his research endeavors and insisted that asylums had a decisive part to play in clinical research.19 Indeed, those relations were crucial not only for Kraepelin’s own clinical research, which relied extensively on follow-up examinations, but also for Rüdin’s later genealogical studies.20 Kraepelin went on to introduce evening lectures (so-called research evenings) in the clinic and arranged for “scientific vacations” that allowed young psychiatrists to pursue their research free of institutional responsibilities. And finally, he also began offering annual postgraduate seminars (Fortbildungskurse) that lasted for two weeks each fall and attracted participants from throughout Germany and abroad. All of these arrangements were designed to strengthen and reinforce the research environment in the clinic and contributed to its international renown.21 While Kraepelin encountered relatively few difficulties reorganizing the internal structures of his own institution and establishing contacts with regional care facilities, in other respects he found it much more difficult to manipulate the environment in which his clinical research was situated. His involvement in the abstinence movement and his campaign to raise awareness of the social costs of alcoholism encountered far more intractable resistance.22 Of all his endeavors, none was pursued as passionately and doggedly as his fight against alcoholism; if there was one domain in which he wished his views to prevail upon public policy, it was alcoholism. Consequently, it is especially instructive to examine his experiences dealing with state officials on this issue. True to his convictions, in 1906 Kraepelin brought together several dozen prominent Munich burghers to found a society dedicated to the construction of asylums for alcoholics.23 Over the years, Kraepelin was active on behalf of this and other temperance organizations. In the most polemical of all his writings, he waged a long and drawn out battle against alcohol abuse and for improved care of alcoholics. Yet the Bavarian government never responded with anything like the passion that Kraepelin brought to the issue. Indeed, it was highly skeptical of his endeavors and worked to thwart their design. It suspected that Kraepelin’s motives had more to do with alleviating the burdens that alcoholics placed on his institution than with any serious attempt at addressing the general problems of alcoholism.24 The government therefore consistently refused to build the asylums that Kraepelin sought, even though he had successfully recruited substantial matching funds for the project. Faced with this opposition and after years of lobbying, Kraepelin abandoned his efforts and, in 1912, resigned from his prestigious post on the Bavarian Medical Board in frustration and disillusionment.25 One of the consequences of his resignation was that in spite of his international renown Kraepelin was excluded from official deliberations on new insanity legislation (Irrengesetz) that became law in Bavaria in 1914.

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Two further encounters also help illuminate Kraepelin’s attitudes toward state support for psychiatric research. In 1906 he petitioned the Bavarian Ministry of War to conduct experiments on the effects of alcohol on the accuracy of army marksmen. At the time, it was common policy in German armies to distribute alcohol and Kraepelin suspected that it had a detrimental impact on the fighting force of the troops. After long and arduous negotiations, Kraepelin was finally allowed to carry out the experiments in October of 1907. Much to his chagrin, however, the army concluded from his results that the performance of its troops was “almost entirely” unaffected by the alcohol ration and it took no action on his recommendations.26 With the outbreak of World War I Kraepelin again approached the ministry of war. This time he was likewise concerned about the impact of alcohol on the troops, although now he worried that alcohol consumption could heighten the risk of contracting syphilis. He therefore proposed using the Wassermann test to examine the entire Bavarian army. But his proposal was rejected by the army, not least on the grounds that it would threaten the morale of the troops. Although the army agreed to a limited number of tests, it placed such restrictions on them that Kraepelin was forced to abandon his efforts.27 Kraepelin’s ambiguous relationship with the state is perhaps nowhere more in evidence than in his efforts to found a psychiatric research institute.28 He articulated his views on research institutes shortly after Wilhelm II announced the creation of the Kaiser-Wilhelm-Gesellschaft in October 1910.29 The Kaiser’s announcement had set out a new government policy of financing institutes dedicated strictly to scientific research. The occasion Kraepelin chose to expound upon his views was a meeting of the local Munich chapter of the German Hochschullehrertag in early 1911.30 The Hochschullehrertag, of which Kraepelin was a founding member, had been established in 1907 out of concern for the growing influence of the state on academic affairs. The organization represented an attempt to defend the corporate interests of university faculty from the effects of bureaucratic centralization.31 Kraepelin’s presentation echoed the views of Adolf von Harnack, who had been instrumental in conceptualizing the new KaiserWilhelm-Gesellschaft. Like von Harnack, Kraepelin too seemed to uphold the Humboltian principle of unifying teaching and research by advocating a close association of universities and research institutes. At the same time, however, he undercut that principle by locating the institutes outside the corporate structure of the university. Furthermore, Kraepelin pointed to the establishment of large research institutes abroad to highlight the dangers facing German science if it remained linked to the university and hence burdened with academic responsibilities. Beyond these structural limitations, he also believed that the Wilhelmine state was no longer able to muster the necessary financial resources to support large-scale research. Indeed, it

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had become more difficult to convince officials of the importance of pure research because they viewed it as a deferrable luxury and at times as even wholly incompatible with the priorities of the state. Given the difficulties of acquiring state research funding, Kraepelin looked with considerable envy on secondary education in North America. There was, in his mind, no doubt that private funding sources were far more lucrative than the support that cash-strapped and unpredictable legislatures could provide. The example of North America proved that “the enthusiasm of the wealthy classes for scientific progress could help set research free and that state funding alone could no longer meet the challenges facing contemporary science.”32 Referring specifically to the Carnegie Foundation and the Institut Pasteur, he believed that the dimensions of these facilities surpassed by far the capacities of German universities. In spite of their illustrious past, German universities could no longer compete with these larger entities and would soon be relegated to insignificance. Kraepelin’s views appear to have found the approval of his psychiatric colleagues. At the annual meeting of the Society of German Alienists in 1912 he was given the task of drafting a formal proposal for a research institute. And a year later, when he reported back to the society, it was agreed that his recommendations be submitted to the Kaiser-Wilhelm-Gesellschaft.33 Ultimately, however, Kraepelin’s proposal was rejected, partly because of a rival proposal for an institute of brain research in Berlin, and partly because it linked the research institute to a hospital.34 Following this setback, Kraepelin contemplated submitting the proposal directly to the German Reichstag. But this plan appears to have been rejected for fear of entering an unpredictable legislative labyrinth and because of the dubious prospect of seeing the institute weighed down by bureaucratic regulations and subordinated to interests of the Imperial administration.35 Shortly after these plans were abandoned, the First World War broke out and it looked as though Kraepelin’s proposal would be put on ice indefinitely.

World War I The war only further impressed upon Kraepelin the need for such an institute. Given the terrible carnage that the war was inflicting on the German people, he believed that a research institute had become a biopolitical imperative. Convinced that the survival of the German people was teetering in the balance and that a research institute was essential in the battle against the “internal enemy” of madness, he published his proposal in early 1916.36 Shortly thereafter in 1917—in the midst of war—Kraepelin finally managed to found the Deutsche Forschungsanstalt für Psychiatrie (DFA) in Munich.37 But he did so by mobilizing private, not state, funding. With the aid chiefly of

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James Loeb, an heir to the New York banking firm Kuhn, Loeb & Co, as well as support from the German industrialists Carl Duisberg and Gustav Krupp von Bohlen und Halbach, Kraepelin was able to establish his research institute. He believed the institute’s survival would depend not on state subsidies but on private foundations: Unfortunately, we will never be able to count on the state to provide funding for a full-scale research institute because it is constrained by its consideration of the tax payer. Hence, private foundations will have to intervene as they have with huge sums of money for other research institutes, especially in foreign countries.38

Kraepelin went on to stress that this kind of funding might even be more advantageous for the institution since it ensured greater flexibility. He was certainly sensitive to difficulties that could arise if donors sought to influence psychiatric research and he therefore insisted on complete autonomy in setting the institute’s agenda. But on the whole, he judged these dangers to be negligible. Thus, on issues of the utmost importance for his psychiatric research agenda, Kraepelin found philanthropic sponsors to be more pliable and forthcoming. And indeed, into the 1930s, funding for the DFA was derived chiefly from private donations.39 Kraepelin’s appreciation of the benefits of philanthropy had been reinforced by his own experiences in the United States and the support he had received from American benefactors. Kraepelin traveled to the United States on two occasions, once in 1908 and again in 1925.40 His first visit there had been to treat Stanley McCormick, son of Cyrus Hall McCormick, the famous inventor of the McCormick reaper and one of the wealthiest individuals in the country.41 For his services to the McCormick family, Kraepelin is reputed to have pocketed some fifty thousand marks.42 Such happy circumstances undoubtedly shaped his perceptions of American philanthropy and ultimately fed into the critique of research funding in Germany by demonstrating the potential benefits of operating outside the narrower boundaries of state sponsored research. In his efforts to mobilize funds from private sources, Kraepelin tailored his appeals to fit the motives driving philanthropic spending. For example, he appealed to philanthropists’ personal experiences; in his correspondence with American associates, Kraepelin repeatedly stressed that former patients or their relatives were optimal targets in the recruitment of financial support.43 As early as 1904, Kraepelin’s reputation was such that a daughter of John Rockefeller received psychiatric treatment from him in Munich.44 The DFA’s chief benefactor, James Loeb, was afflicted by psychiatric illness and had likewise been treated by Kraepelin.45 The nephew of Gustav Krupp von Bohlen und Halbach was admitted to the Munich clinic after suffering head

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wounds during the First World War. And Amalie Caro, an ardent supporter of the DFA and the daughter of Heinrich Caro, the technical director of Germany’s largest chemical firm, Badische Anilin-und Soda Fabrik (BASF), had been Kraepelin’s patient in the 1890s. Kraepelin also appealed to benefactors’ nationalist sentiments and their identification with German interests. James Loeb, for example, had left the United States and settled in Europe to pursue his interests in art and was known to be sympathetic to German culture. Kraepelin’s project also appealed to the promise of psychiatric science to ameliorate public protest over the German chemical and steel industries and thereby enhance national resolve in the midst of war. One of the most important fields of research to be pursued by the DFA was experimental psychology and Kraepelin appears to have been extremely adroit in arguing its potential benefits when applied to the industrial workplace.46 For years his experimental research had attracted the attention of advocates of industrial management because it appealed to utopian visions of a more thoroughly rationalized workplace.47 In the midst of war, just as the German government sought to defuse political and class tensions by appealing to nationalist sentiments (Burgfrieden), Kraepelin’s psychophysical research seems to have held out the promise of a scientific solution to deep-seated socioeconomic divisions within German society. Such prospects appealed to industrialists concerned about maintaining production on a war footing. Kraepelin also appears to have been adept at pitching his arguments so that they appealed to the pecuniary sensibilities of his audience. One proposal is especially instructive in this regard. As part of his early efforts to woo philanthropic support, Kraepelin proposed a structural plan that would allow the research institute to be built at lower cost. That plan involved the institute’s genealogical and demographic department. Because he believed that research on degeneration was “the most important question of all,” he could not envision an institute without such a department. Nevertheless, he was prepared to see the department housed elsewhere and suggested that it be associated with the Imperial Office of Health (Reichsgesundheitsamt).48 This institutional configuration would save money and have the advantage of being able to “draw on public resources for research purposes.”49 Although these plans never came to fruition, by proposing to outsource the genealogical and demographic section he was wagering on being able to sell a restricted version of his institute to potential benefactors while simultaneously exploiting the state’s information gathering apparatus to advance his own research aims. In effect, Kraepelin was negotiating the conditions and boundaries within which he believed effective research could be conducted. In this context it is worth recalling Kraepelin’s remark of 1918 that “an omnipotent ruler, guided by our current knowledge and able to intervene ruthlessly in the affairs of men, could in a few decades certainly reduce levels

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of insanity.”50 Given the subsequent rise of national socialism in Germany, Kraepelin’s words have acquired ominous prescience. It is therefore worth recalling the context in which this remark was made. In his reflections on the state of psychiatric care in Germany, Kraepelin envisioned two conjoined (and mutually compatible) paths toward a better world. The first lay in the field of prophylaxis. He believed that nearly a third of all psychiatric disorders where amenable to prophylactic efforts. Most prominently, hereditary degeneracy, alcoholism, and syphilis could be alleviated through preemptive measures. It was here that Kraepelin dreamed of the intervention of an omnipotent ruler. He went on to argue, however, that the difficulties posed by madness would ultimately not be “solved” by political means: Progress in understanding the nature of mental disorder was possible “only with the help of scientific research.”51 This second path toward a better psychiatric world demanded the systematic support of scientific research with substantial resources. In the case of the DFA, this support had come—as Kraepelin hastened to point out—chiefly from nonpublic sources.

Kraepelin in the USA (1925) As successful as Kraepelin had been in fostering the emergence of the DFA during World War I, German defeat in 1918 represented daunting challenges to the fledgling institute’s further development. Efforts to maintain its financial solvency had to cope with the collapse of the German monetary system following the war and the rampant inflation of 1923—upheavals that twice obliterated the DFA’s endowment.52 The patriotic arguments that Kraepelin had deployed during the war had now also to be recast to fit postwar realities. However, because of his own uncompromising militaristic stance during the war, Kraepelin’s fund-raising efforts were hobbled from the outset. Shortly after the war, he had explored the possibilities of financial support from philanthropists in the United States.53 He accompanied his appeals with an article published in 1918 that justified the DFA on the grounds that it was essential to the survival of the German Volk.54 In response to his entreaties, Adolf Meyer recommended that because of “deeply rooted national feelings” Kraepelin would do best to direct his appeals to Germanophile benefactors like Alfred Heinsheimer, Jakob Henry Schiff, and the Warburg family.55 Responding to Meyer’s hopes that the wounds of war would be overcome, Kraepelin remarked that “the conduct of our prior enemies has made it extraordinarily difficult to see that wish fulfilled. If in the foreseeable future it will be at all possible to ameliorate the remaining, deep animosities, then the responsibility for accomplishing this task will fall first and foremost to scientific institutions.”56 It must be said, however, that this internationalist argument seems to have

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been motivated more by the necessities of fund-raising than by any abiding commitment to international scientific cooperation.57 For it was not Kraepelin but rather the DFA’s chief benefactor, James Loeb, who had insisted that the institute be a center of international research modeled after the marine biological research facilities at Naples, Italy and Woods Hole, Massachusetts.58 After the war, Kraepelin remained as convinced as ever that German science was preeminent in the world. When Adolf Meyer visited Germany in 1923, he was taken aback by the same “ardent” and “unregenerate” nationalism that had prompted Kraepelin to agitate for unrestricted submarine warfare during the war.59 Thus, Kraepelin’s efforts to make the DFA a center of international research had more to do with economic necessity than with any belief that German psychiatry could benefit from international scientific cooperation. Kraepelin’s efforts to attract support for the DFA culminated in a second trip to the United States in 1925.60 He undertook this journey for both research and fundraising purposes. In terms of research, in early 1924 he began collecting information for a comparative study on the frequency of progressive paralysis in nonwhite populations. His trip to the United States was designed to collect data on Native and African American populations for this study.61 While there, he worked at the Library of the Surgeon General’s Office in Washington, DC and conducted extensive clinical examinations and Wassermann tests. Together with his colleague Felix Plaut, he examined hundreds of patients at both St. Elizabeths Hospital in Washington, DC and at an American Indian asylum in Canton, South Dakota. Kraepelin also used his time in the United States to study the effects of prohibition on mental illness and met with representatives of the Anti-Saloon League.62 Kraepelin was also interested in occupational psychology and the Taylor system in the United States. In a letter to the German industrialist Krupp von Bohlen und Halbach prior to his departure, he stressed that the economic ramifications of occupational psychology had not yet received adequate attention and that more scientific research in this field was needed.63 Kraepelin had read Henry Ford’s writings and arranged to visit the Ford Motor Company to see how the principles of industrial management were being applied in practice. More important, however, Kraepelin’s interest in Henry Ford’s factories was inextricably linked with his efforts to locate financial support for the DFA.64 Henry Ford, as both a benefactor of an asylum for psychopathic girls in Detroit65 and a potentially receptive target for ideas about industrial psychology, was a prime, though ultimately illusive, target of Kraepelin’s fund-raising endeavors. In spite of his unflagging efforts, clearly Kraepelin’s own nationalist sentiments threatened to undercut his fund-raising initiatives. One revealing episode was recounted by George Kirby, an American psychiatrist who in 1906 had spent several months working under Kraepelin in Munich. In a letter to Adolf Meyer, he described an encounter with Kraepelin in New York City:

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We had an interesting evening, but the conversation turned more to the war and political issues than to psychiatric topics. We all felt quite disappointed to learn that Professor Kraepelin can see no solution of the Franco-German problem except another war and the ultimate domination of France by Germany. He seems to be not at all interested in any plan whereby mutual confidence and understanding could be established between the two countries.66

Even those sympathetic to German interests were taken aback by Kraepelin’s nationalist fervor. When he met Jakob Schiff upon his arrival in New York, Kraepelin sensed an “unfriendly disposition to Germany” and saw himself forced into a “vigorous” defense of his country.67 And Kraepelin’s engagements in Boston had also resulted in “considerable adverse feelings” when discussions turned to political issues.68 On his final fund-raising effort before returning to Europe in June of 1925, Kraepelin visited the offices of the Rockefeller Foundation in New York.69 Although he reported that the meeting had proceeded well, when Rockefeller officials later queried Adolf Meyer they learned something about the brusque encounters that Kraepelin’s visit had generated. Asked to report on Kraepelin’s request for funding, Meyer wrote cryptically: Unfortunately, at the time of his visit he created at the very end a situation rather embarrassing to me, showing a display of German diplomacy that has rather shaken my willingness of support. On the other hand I feel that he himself is after all close to his age limit, and that it might be possible to keep a strong group of investigators together on their own merits. Moreover, his yielding to a very peculiar personal temptation should perhaps not be allowed to figure in the recognition of what services he has rendered in promoting a certain phase of psychiatry.70

Officials at the Rockefeller Foundation appear to have shared these views. In responding to Meyer’s report, the director of the medical division of the Rockefeller Foundation, Richard M. Pearce, wrote that I am actuated however largely by the fact that I consider Munich a good center for this work and that setting aside all consideration of Kraepelin himself, he has brought together a strong group of investigators and there should be no doubt about the continuance of the work and its success.71

Hence, it would appear that it was not so much Kraepelin’s personal appeals that tipped the scales in favor of his funding requests. On the contrary, the financial support garnered by the DFA in 1926 appears to have come in spite of Kraepelin’s entreaties, not because of them. Certainly the motives of the Rockefeller Foundation were complex and multidimensional, but they seem

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to have been determined more by considerations of the future potential of the DFA’s research scientists than by the awkward and belligerently nationalistic legacy of its founder.

Conclusion After returning to Munich, Kraepelin immediately sought to shore up the fund-raising work he had undertaken in the United States. In a letter to the president of the Kaiser-Wilhelm-Gesellschaft, he suggested contacting the U.S. ambassador in Berlin, hoping that the plight of the DFA would provide the ambassador “a good opportunity to demonstrate his sympathies for Germany and to contribute to the reconciliation between the two peoples on wholly neutral territory.”72 This suggestion reflects how, especially after World War I, Kraepelin had come to understand his appeals for financial support as opportunities for donors to demonstrate their sympathies for Germany. Throughout his life, Kraepelin remained convinced of German psychiatry’s preeminence; international scientific cooperation was never a priority in his considerations of how best to advance psychiatric knowledge. This is not to say, however, that he was averse to strategies that could marshal international resources in support of his research institute. In fact, he became increasingly convinced that—as he understood it—American-style philanthropy could significantly enhance psychiatric research and compensate for the shortcomings and limitations of Germany’s at once vaunted, but ailing, research institutions. Given these views, it would be a mistake to suggest that Kraepelin’s research was beholden to the interests of the German state. Throughout this article, I have sought to emphasize that Kraepelin was not a simple instrument of state power; nor was he able simply to impose his research agenda and psychiatric maxims on state policies. I have argued instead that his experiences with public officials contributed to a decidedly ambiguous attitude on his part about the state’s ability to support psychiatric research. Historians will therefore need more complex models to understand and explain how psychiatric research agendas, and the strategies that psychiatrists deployed to advance those agendas, emerged and evolved. Although I have not attempted it here, in the future they will need to find ways to integrate narratives about Kraepelin’s nosological accomplishments with the practical necessities of organizing psychiatric research—to weave together a richer tapestry that accounts not only for Kraepelin’s taxonomic achievements but also for the strategies he employed to facilitate and undergird his clinical research agenda.

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Notes 1. See Eric J. Engstrom and Matthias M. Weber, “Making Kraepelin History: A Great Instauration?” History of Psychiatry 18, no. 3 (2007): 267–73. 2. Werner Leibbrand and Annemarie Wettley, Der Wahnsinn: Geschichte der abendländischen Psychopathologie (Freiburg: Karl Alber, 1961), 579, and Hans-Georg Güse and Norbert Schmacke, Psychiatrie zwischen bürgerlicher Revolution und Faschismus (Kronberg: Athenäum Verlag, 1976), 180. 3. See Dirk Blasius, Einfache Seelenstörung: Geschichte der deutschen Psychiatrie 1800–1945 (Frankfurt am Main: Fischer, 1994), 80–115. 4. See Eric J. Engstrom, Clinical Psychiatry in Imperial Germany: A History of Psychiatric Practice (Ithaca: Cornell University Press, 2003), 121–46; Wolfgang Burgmair, Eric J. Engstrom, and Matthias M. Weber, eds. Emil Kraepelin: Kraepelin in Heidelberg, 1891–1903 (Munich: Belleville, 2005). 5. Kraepelin to Ministry of Justice, Culture, and Education, 2 August 1899, I/1, Archive of the Psychiatric Clinic of the University of Heidelberg. 6. Emil Kraepelin, Die psychiatrischen Aufgaben des Staates (Jena: Fischer, 1900). 7. Nevertheless, Kraepelin rejected calls for national legislation because it would subject psychiatric interests to the whims of parliamentary debate and to jurists who were enthralled by the “spector of incarceration.” Instead, he preferred to rely on administrative orders that were more pliable and adaptable to local circumstances. See Offizieller Bericht über die Zweite Hauptversammlung des deutschen Medizinalbeamten-Vereins zu Leipzig (Berlin: Fischer’s Medizinische Buchhandlung, 1903), 14. 8. Kraepelin, Die psychiatrische Aufgaben des Staates, 2–6. 9. For a full bibliography of Kraepelin’s writings, see Wolfgang Burgmair, Eric J. Engstrom, and Matthias Weber, Emil Kraepelin: Persönliches-Selbstzeugnisse (Munich: Belleville, 2000), 243–66. 10. Prior to 1900, Kraepelin had also called for state-supported “mass psychiatry,” but his aim then had more to do with issues concerning diagnostic and nosological precision than with social engineering. See Eric J. Engstrom, “La ‘messende individualpsychologie’: sur l’importance de l’expérimentation psychologique dans la psychiatrie d’Emil Kraepelin,” Psychiatrie—Sciences Humaines—Neurosciences 1, no. 1 (2003): 53–61, and no. 2 (2003): 40–46. 11. Kraepelin, Die psychiatrischen Aufgaben des Staates, 6. 12. Kraepelin, “Zur Entartungsfrage,” Zentralblatt für Nervenheilkunde und Psychiatrie 31 (1908): 748. For a translation and introduction to this article, see Eric J. Engstrom, “On the Question of Degeneration,” History of Psychiatry 18, no. 3 (2007): 389–404. 13. The situation in Munich had been desolate. Kraepelin himself complained that the academic hospital had only “two small rooms with 13 beds apiece and a few distant cells. With only one night watchman at its disposal, this ward admitted between 600 and 700 patients a year and, lacking its own bathing facilities, was forced to use those of the syphilitic ward.” Kraepelin, Die psychiatrischen Aufgaben des Staates, 18. 14. See Ministry of the Interior for Religious and School Affairs (SMIKSA) to Kraepelin, 11 March 1907 and 10 March 1908, MK 11158, Bayerisches Hauptstaatsarchiv (BHStA), Munich.

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15. On broader contextual issues concerning Kraepelin’s tenure in Munich, see Emil Kraepelin, Kraepelin in München I, 1903–1914, ed. Wolfgang Burgmair, Eric J. Engstrom, and Matthias Weber (Munich: Belleville, 2006). 16. SMIKSA to University Senate, February 1907, MK 11245, BHStA, Munich. 17. Kraepelin to University Administrative Counsel, 16 May 1908, MK 11243, BHStA, Munich. 18. SMIKSA to University Administrative Counsel, 24 May 1905, MK 11245, BHStA, Munich. 19. See Emil Kraepelin, “Fragestellungen der klinischen Psychiatrie,” Centralblatt für Nervenheilkunde und Psychiatrie 28 (1905): 589–90. 20. See C. K. Clarke, “Notes on Some of the Psychiatric Clinics and Asylums in Germany,” American Journal of Insanity 65 (1908–9): 365–66. 21. On these efforts, see also Emil Kraepelin, Lebenserinnerungen (Berlin: Springer, 1983), 135–37. Kraepelin would later complain that initially he had had difficulty infusing the clinic with “scientific spirit” and that many of the measures he implemented in Munich did not live up to his expectations. 22. On Kraepelin’s work in the abstinence movement, see Thomas Schmidt, Emil Kraepelin und die Abstinenzbewegung (Medical Dissertation, University of Munich, 1982). 23. For details see Eric J. Engstrom, “Emil Kraepelin: Psychiatry and Public Affairs in Wilhelmine Germany,” History of Psychiatry 2 (1991): 114–19. 24. See the ministry’s remarks on Emil Kraepelin to SMIKSA, 12 December 1906, MK 11168, BHStA, Munich. 25. See Münchner Neueste Nachrichten, 12 May 1912. 26. Breitkopf to Ministry of War, 7 November 1907, MKr 10095, BHStA Abt. IV, Munich. See also Kraepelin, Lebenserinnerungen, 172; Kraepelin, “Die Beeinflussung der Treffsicherheit beim Schiessen durch Alkohol,” Internationale Monatsschrift zur Erforschung des Alkoholismus und Bekämpfung der Trinksitten 26 (1916): 265–70; and Martin Lengwiler, “Psychiatry Beyond the Asylum: The Origins of German Military Psychiatry Before World War I,” History of Psychiatry 14, no. 1 (2003): 41–62. 27. For details see Engstrom, “Emil Kraepelin: Psychiatry and Public Affairs in Wilhelmine Germany,” 119–22. On the relationship between psychiatry and the military, see Martin Lengwiler, Zwischen Klinik und Kaserne: Die Geschichte der Militärpsychiatrie in Deutschland und der Schweiz, 1870–1914 (Zurich: Chronos, 2000). 28. On the origins of the institution see Emil Kraepelin, Kraepelin in München II, 1914–1921, ed. Wolfgang Burgmair, Eric Engstrom, and Matthias Weber (Munich: Belleville, 2009), 60–80. 29. See Lothar Burchardt, Wissenschaftspolitik im Wilhelminischen Deutschland: Vorgeschichte, Gründung und Aufbau der Kaiser-Wilhelm-Gesellschaft zur Förderung der Wissenschaften (Göttingen: V&R, 1975). 30. Emil Kraepelin, “Forschungsinstitute und Hochschulen,” Süddeutsche Monatshefte 8 (1911): 597–607. 31. See Verhandlungen des ersten deutschen Hochschullehrer-Tages zu Salzburg (Straßburg: Karl Trübner, 1908). Kraepelin used this forum as early as 1908 to articulate his views on university reform. See Emil Kraepelin, “Die Auslese für den akademischen Beruf,” in: Kraepelin in München 1903–1914, sec. 3.2.

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32. Kraepelin, “Forschungsinstitute und Hochschulen,” 597. 33. See Kraepelin, Lebenserinnerungen, 167–68, and Fritz Siemens, “Die Errichtung eines biologischen Forschungsinstitutes über die körperlichen Grundlagen der Geisteskrankheiten,”Allgemeine Zeitschrift für Psychiatrie 69 (1912): 725–31. See also Psychiatrisch-Neurologische Wochenschrift 15 (1913/14): 303, and Kraepelin to Meyer, 28 December 1912, I/2188/1, Adolf Meyer Papers, The Alan Mason Chesney Medical Archives (AMCMA), Baltimore. 34. Not until 1924 did the Deutsche Forschungsanstalt für Psychiatrie became a part of the Kaiser-Wilhelm-Gesellschaft. See von Harnack to Prussian Minister of Education, 28 May 1924, 2428, KWG Generalverwaltung, Archiv zur Geschichte der Max-Planck-Gesellschaft (AGMPG), Berlin. 35. See the review of “Eine deutsche Forschungsanstalt für Psychiatrie” Psychiatrisch-Neurologische Wochenschrift 19 (1917/18): 22. 36. Emil Kraepelin, “Ein Forschungsinstitut für Psychiatrie,” Zeitschrift für die gesamte Neurologie und Psychiatrie 32 (1916): 1–38. 37. See Kraepelin, Lebenserinnerungen, 201–3. For additional details see Emil Kraepelin, Kraepelin in München II, 1914–1921, 60–80. 38. Emil Kraepelin, “Die deutsche Forschungsanstalt für Psychiatrie,” Die Naturwissenschaften 6 (1918): 337. 39. See Matthias Weber, Ernst Rüdin: Eine kritische Biographie (Berlin: Springer, 1993), 117–24. 40. On the trips see Kraepelin, Lebenserinnerungen, 172–73; Kraepelin, Kraepelin in München I, 1903–1914, sec. 5.1; Christoph Bendick, Emil Kraepelins Forschungsreise nach Java im Jahre 1904: Ein Beitrag zur Geschichte der Ethnopsychiatrie, Arbeiten der Forschungsstelle des Instituts für Geschichte der Medizin der Universität Köln, vol. 49 (Cologne: Hansen, 1989), 86–92. 41. See Richard Noll, “Styles of Psychiatric Practice, 1906–1925: Clinical Evaluations of the Same Patient by James Jackson Putnam, Adolph Meyer, August Hoch, Emil Kraepelin, and Smith Ely Jelliffe,” History of Psychiatry 10 (1999): 145–89. For a more comprehensive investigation of the case, see the unpublished manuscript “Let Freud Come See Me” by Doris B. Nagel of New York City. I would like to thank Dr. Nagel for placing excerpts of her manuscript at my disposal. 42. Carl G. Jung to Sigmund Freud, 7 January 1909, in The Freud/Jung Letters: The Correspondence between Sigmund Freud and C. G. Jung, ed. William McGuire, trans. Ralph Manheim and R. F. C. Hull (Princeton: Princeton University Press, 1974), 194. 43. See, for example, Kraepelin to Mrs. Emmons Blaine, 21 January 1920, IE 358, Anita McCormick Blaine Papers, State Historical Society of Wisconsin, Madison. My thanks to Dr. Doris B. Nagel for showing me this letter. 44. Gaupp to Meyer, 13 December 1905, I/1318/1, Adolf Meyer Papers, AMCMA, Baltimore. Additional research is necessary to determine whether this treatment has any relation to the major grant that the DFA received from the Rockefeller Foundation shortly before Kraepelin’s death in 1926. See Rockefeller Foundation to Emil Kraepelin, 27 May 1926, K 25/2, Kraepelin Papers, MPIP-HA, Munich. 45. On Loeb, see Wolfgang Burgmair and Matthias Weber, “‘Daß er sich nirgends wohler als in Murnau fühle . . . ‘ James Loeb als Förderer der Wissenschaft und philanthropischer Mäzen,” Schriften des historischen Vereins Murnau am Staffelsee 18 (1997): 77–128.

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46. See Kraepelin, Lebenserinnerungen, 205–6. 47. See, for example, Max Weber, “Zur Psychophysik der industriellen Arbeit,” Archiv für Sozialwissenschaft und Sozialpolitik 28 (1908): 219–77, 719–61. 48. In 1910 Robert Sommer had also proposed an affiliation with the Reichsgesundheitsamt on the grounds that contemporary clinical research, investigations into the hereditary causes of insanity, and the findings of forensic science had all demonstrated that psychiatry was, to a considerable degree, a “social science.” Robert Sommer, “Eine psychiatrische Abteilung des Reichsgesundheitsamtes,” PsychiatrischNeurologische Wochenschrift 12 (1910): 295. It is worth noting that Sommer advanced his views at an international conference of alienists and published them in a journal for psychiatric practitioners that was held in low regard by Kraepelin’s Munich school. Nevertheless, the idea was quickly adopted by Kraepelin’s colleague Alois Alzheimer, who called for state cooperation with Ernst Rüdin’s statistical research on racial hygiene and eugenics. See Alois Alzheimer, “Ist die Einrichtung einer psychiatrischen Abteilung im Reichsgesundheitsamt erstrebenswert?” Zeitschrift für die gesamte Neurologie und Psychiatrie 6 (1911): 242–46. On these developments see also Volker Roelcke, “Die Entwicklung der Psychiatrie zwischen 1880 und 1932: Theoriebildung, Institutionen, Interaktionen mit zeitgenössischer Wissenschafts-und Sozialpolitik,” in Wissenschaften und Wissenschaftspolitik: Bestandsaufnahmen zu Formationen, Brüchen und Kontinuitäten im Deutschland des 20. Jahrhunderts, ed. Rüdiger vom Bruch and Brigitte Kaderas (Stuttgart: Steiner, 2002), 118. 49. Kraepelin, “Ein Forschungsinstitut für Psychiatrie,” 30. Bavarian officials had proven to be accommodating when it came to supporting Ernst Rüdin’s genealogical work. In February of 1912 Kraepelin had petitioned the Ministry of Education, seeking access to the student files in Bavarian primary schools. At that time permission was quickly granted, albeit with one significant proviso. In order to “avoid problems” officials refused to issue a public announcement to school principals of Kraepelin’s intentions. Instead, he was instructed to present the ministry’s letter to the school principals in order to be granted access to the files. The information gathered in this way formed the basis of Rüdin’s book Zur Vererbung und Neuentstehung der Dementiapraecox, which was completed in 1914 and later published in 1916. See SMIKSA to Emil Kraepelin, 28 February 1912, MK 11158, BHStA, Munich. 50. Kraepelin, “Hundert Jahre Psychiatrie,” Zeitschrift für die gesamte Neurologie und Psychiatrie 38 (1918): 270. 51. Ibid. 52. For details on the financial situation of the DFA after the war see Weber, Ernst Rüdin, 120–24. 53. See Kraepelin to Adolf Meyer, 3 November 1919, I/2188/1, Kraepelin to Henry Phipps, 7 November 1919, I/3081/16; Kraepelin to Anita Blaine, 21 January 1920, all in Adolf Meyer Papers, AMCMA, Baltimore. 54. Kraepelin, “Die deutsche Forschungsanstalt für Psychiatrie,” 333–37. 55. Meyer to Kraepelin, 1 December 1919, I/2188/1, Adolf Meyer Papers, AMCMA, Baltimore. 56. Kraepelin to Adolf Meyer, 7 January 1920, I/2188/1, Adolf Meyer Papers, AMCMA, Baltimore. 57. Cf. Kraepelin’s derogatory views on international scientific conferences in Kraepelin, Kraepelin in Munich 1903–1914, sec. 5.1.

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58. Loeb to Kraepelin, 18 December 1915, DFA 2/1, Kraepelin Papers, MPIPHA, Munich. 59. See Adolf Meyer’s manuscript “My impressions of Europe,” VI/7/32, Adolf Meyer Papers, AMCMA, Baltimore. 60. His travels took him down the eastern seaboard from New York to Philadelphia, Baltimore, and Washington, before traveling inland to Buffalo, Detroit, Chicago, and Canton, South Dakota. In Canton, he spent three days visiting an asylum for Indians before proceeding to Pasadena for a consultation. Via Mexico City he then returned to Boston and New York before sailing for Europe aboard the SS Albert Ballin on 11 June 1925. 61. On this aspect of the trip see Felix Plaut, Paralysestudien bei Negern und Indianern: Ein Beitrag zur vergleichenden Psychiatrie (Berlin: Springer, 1926). For Kraepelin’s views on paralysis at this time see Kraepelin, “Das Rätzel der Paralyse,” Die Naturwissenschaften 12 (1924): 1121–31. 62. Kraepelin to R. Hercod, 6 January 1925, K 37/4, Kraepelin Papers, MPIPHA, Munich. 63. Kraepelin to Krupp von Bohlen und Halbach, 10 December 1924, 2428, KWG Generalverwaltung, AGMPG, Berlin. 64. Kraepelin to Karl-Oscar Bertling, 23 February 1925, K 37/2, Kraepelin Papers, MPIP-HA, Munich. 65. Alwin Knauer to Kraepelin, 15 February 1925, K 37/2, Kraepelin Papers, MPIP-HA, Munich. 66. George Kirby to Adolf Meyer, 27 March 1925, I/2188/2, Adolf Meyer Papers, AMCMA, Baltimore. 67. See Emil Kraepelin to Ina Kraepelin, 26 March 1925, K23, Kraepelin Papers, MPIP-HA, Munich. 68. Notes of Adolf Meyer, probably as a draft letter to Spielmeyer, n. d., I/3634/1, Adolf Meyer Papers, AMCMA, Baltimore. 69. Kraepelin to Mrs. Emmons Blaine, 14 June 1925, 1E 358, Anita McCormick Blaine Papers, State Historical Society of Wisconsin, Madison. 70. Meyer to Pearce, 11 September 1925, III/276/4, Adolf Meyer Papers, AMCMA, Baltimore. 71. Pearce to Meyer, 23 September 1925, III/276/4, Adolf Meyer Papers, AMCMA, Baltimore. 72. Kraepelin to Director of the Kaiser-Wilhelm Gesellschaft, 11 August 1925, 2450, KWG Generalverwaltung, AGMPG, Berlin.

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Chapter Four

Germany and the Making of “English” Psychiatry The Maudsley Hospital, 1908–1939 Rhodri Hayward English psychiatry was defined in relation to its German counterpart for much of the first half of the twentieth century. In British psychiatric writings, Germany served variously as a model of psychiatric organization and research, a source of training and manpower, or as a moral warning on the dangers of political corruption and the decadence of intellectual ambition. This paper does not try to explore the merits of German psychiatry in this period—it gladly passes that task on to the contributions of Eric Engstrom and Volker Roelcke. Rather it attempts to show how the idea of Germany served as a programmatic resource for individuals engaged in the reshaping of English psychiatry and it takes as its case study the early twentieth-century history of the Maudsley Hospital. From its inception the Maudsley was deeply inspired by developments in German psychiatry. The original proposals for the hospital, developed by the London County Council (LCC) Asylums pathologist, Frederick Mott, were modelled on the university psychiatric clinics of Munich, Berlin, Halle, and Heidelberg.1 Mott had toured these clinics in 1907 and in his preface to that year’s edition of the Archives of Neurology he paid generous praise to the German arrangements: Fortunate indeed would be the community in which there was a fully equipped and well organised psychiatrical clinic, under the control of a University, and dedicated to the solution of such problems. The mere existence of such an institution would indicate that people were as much interested in endeavouring to increase the public sanity, as they were in the results of exploration of the uttermost parts of the earth or the discovery of a new star.2

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As Mott explained, such a clinic would serve both a practical and a scholarly purpose. By setting up “receiving houses” for the noncertified insane, the LCC would offer succor to the afflicted at a point where they were still amenable to treatment while at the same time providing the scientific psychiatrist with the necessary material to carry out a Kraepelinian study of the form and development of incipient mental illnesses.3 Mott believed that those early cases of uncertifiable mental affection termed neurasthenia, psychasthenia, obsession, mild impulsive mania, melancholia, hysteria and hypochondria, which in many instances are really the prodromal stages of a pronounced and permanent mental disorder . . . are often in the hopeful and curable stage and these if studied carefully by trained medico-psychologists, could not fail to yield valuable results in regard to our knowledge of the causation, prevention and cure of insanity. Moreover, when cases are followed up systematically they would throw much light on prognosis in similar cases.4

The Maudsley’s emergence as the first British mental hospital to accept voluntary patients was thus rooted in this Kraepelinian rationale. By treating patients in the incipient stages of mental disorder the hospital rendered visible the specific course and outcome of individual nervous diseases.5 Mott’s proposals won the immediate support of Henry Maudsley, who pledged £30,000 of his personal fortune toward the establishment of such a clinic. This pledge provided Mott with the financial support he needed and in March 1908 his plans were accepted by the LCC asylums committee.6 A year later, in 1909, the council’s engineer, William Clifford Smith, accompanied by two committee members, made an inspection of Kraepelin’s clinic in Munich. Nevertheless it would be another six years before the parliamentary legislation on the voluntary admission of insane patients was passed and the building of the new mental hospital on the German model was completed.7 Mott’s championing of the German psychiatric system was echoed by many of his progressive contemporaries. In 1908, a survey of continental hospital arrangements in the British Medical Journal lamented the fact that Britain lacked “so magnificent an instrument for teaching, research and cure as that recently established in Germany under Professor Kraepelin.”8 In 1912, Ronald Rows, the ambitious superintendent of Lancaster Asylum, reiterated this position, arguing that Germany’s state-funded university psychiatric clinics provided the only effective method for advancing the science of psychiatry.9 German psychiatrists, he contended, had faced problems similar to those of their British colleagues, with demoralized and underpaid junior staff working in overcrowded and intellectually stagnant asylums. Yet in the space of four years (between 1905 and 1909), a progressive set of pay structures and conditions had been implemented, a system of vocational training set up, and an active research culture promoted through courses at the university

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psychiatric clinics. Like Mott, Rows singled out Kraepelin’s clinic at Munich as offering the richest course of instruction, and he admiringly recited the list of lectures in its 1908–9 prospectus. Thus, just as Mott was inspired by the example of the Munich clinic to campaign for the establishment of a voluntary mental hospital in London, it was the national example of Germany that encouraged Rows and his colleagues to begin a campaign for the wholesale reform of British psychiatry. In 1911, arguments over the implementation of a proposed diploma in psychological medicine led to the formation of a “committee on the status of British psychiatry” with Rows as its secretary and Maurice Craig as its president.10 The committee argued that Britain was hampered by its lack of early treatment centers and educational institutions that would promote psychiatric training and research, a grievance echoed by supporters in the Lancet and the British Medical Journal.11 One of the most forceful claims made by Rows and his supporters was that the various forms of asylum organization in Britain and Germany sustained different public perceptions of mental illness. As Tom Pear and Grafton Elliot Smith noted in Shell Shock and Its Lessons (1917), the clinic system developed in Germany allowed patients to escape the stigma of incarceration and thus rapidly reintegrate into their respective communities.12 The Maudsley Hospital thus emerged at the nexus of local and national campaigns for the wholesale reform of British psychiatry. Although the official opening of the hospital was delayed by the outbreak of war and the requisition of its buildings by the Fourth London General Territorial Hospital and later by the Ministry of Pensions, the hospital still functioned as a center for military psychiatric research.13 In 1916 Mott transferred the London County Council’s Central Pathological Laboratory (CPL) from Claybury Asylum to the Maudsley, establishing it as a center for the investigation of war neuroses and as a host institution for refugee scholars.14 Throughout the First World War, Mott maintained his close relationship with continental psychiatry: he worked with Fritz Sano, the exiled superintendent of Antwerp Mental Hospital, on the convolutional patterns of the brain in twins, and with the Romanian neurologist Georges Marinesco on the histology of encephalitis lethargica.15

Mott’s Vision of Psychiatry Mott’s infatuation with the German psychiatric system did not simply inform his institutional vision, it framed his understanding of psychiatry. His pioneer work on general paralyses of the insane had, according to William Collins, integrated the “anatomo-pathological method of Charcot” with the

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new sciences of statistics, eugenics, and sociology.16 Inspired by Kraepelin, he believed in the existence of discrete mental diseases transmitted, he thought, through hereditary influence or toxic infection. Like Kraepelin, he introduced a card system at the Central Pathological Laboratory, using it to trace the onset of insanity in mentally ill parents and their insane children.17 From this investigation, Mott developed his “law of anticipation,” which he later saw confirmed in the model of psychiatric hereditarianism developed by Ernst Rüdin.18 Mott was a committed somaticist, maintaining that “mental processes are subordinate to physiological processes and that mental disorders are due to pathological physiogenic conditions.”19 In particular, he believed that mental health was intimately dependent upon the vigor of the human reproductive system, claiming that those with atrophied ovaries or testes would lack the vital sexual energy to carry them through the stresses of modern life or adolescence.20 In the absence of an adequate supply of this vital energy, Mott believed that the cerebral neurones, in particular those of the supragranular layer, would break down.21 This, he claimed, was the physical basis of the phenomena of dementia praecox as identified by Kraepelin.22 He cited the microscopic researches of Alzheimer and Nissl as evidence for this process of degeneration, arguing mental disease could be traced through the pathological anatomy of the testes and the histology of the cerebral cortex.23 Yet the atrophied testicle did not simply serve as a pathological sign providing a physical measure of mental distress, rather it allowed Mott to reconcile his psychiatric and his sociological projects that connected the psychopathology of the individual to the eugenic failure of the race. Mott retired in 1923, the year that the Maudsley officially opened to the public. He had established a hospital that embodied his ideas on the development of mental disease and he appointed successors who seemed to subscribe to his vision of a somaticist psychiatry based on Kraepelinian principles. Yet his successors were to share none of the bold confidence that had inspired Mott’s work. The new medical superintendent, Edward Mapother, was an asthmatic Anglo-Irishman with a penchant for wrestling and boxing. Although Mapother brought a fierce energy to the administration of the hospital and won the widespread admiration of his staff, he maintained a much more tentative belief in the power of psychiatry and he eschewed the global schemas once espoused by Mott.24 Similarly, Frederick Lucien Golla, the new Anglo-Italian director of the CPL, would abandon his predecessor’s confident somaticism in favor of a much more critical model that refused any straightforward connection between physical causes and psychological effects.25 Instead Golla was to develop a physiological psychology that searched for the bodily concomitants of mental processes while insisting that their complex origins were beyond the scope of scientific representation.

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Golla, Mapother, and the Making of Maudsley Psychiatry Unlike Mott, who had followed Kraepelin in his insistence on the existence of the discrete disease categories in psychopathology, Golla and Mapother pursued a much more skeptical agenda.26 Although they did not deny the possible veracity of Kraepelin’s system and frequently professed admiration for his clinical methods, they believed that such diagnoses underestimated the psychobiological complexity of the disturbed individual.27 Against Kraepelin, Golla and Mapother argued that disease categories were simply convenient fictions that had been developed to legitimate treatment regimes and facilitate hospital administration. At the 1926 meeting of the British Medical Association, Mapother tried to evangelize for this theory but met with widespread criticism and condemnation.28 The meeting’s chairman, Farquhar Buzzard, castigated him for his failure to distinguish between neuroses and psychoses, and Thomas Ross of the Cassel Hospital argued that Mapother’s nominalist position was itself an artefact of the Maudsley’s admissions policy, claiming that the absence of chronic cases in the hospital insulated Mapother from any direct engagement with cyclical psychoses.29 Five years later Mapother was to reverse Ross’s critique, declaring that the Maudsley’s admissions policy allowed its clinicians to transcend the administrative nosologies relied upon by their colleagues working in the county asylums. He argued that the hospital’s policy of allowing only voluntary admission enshrined Henry Maudsley’s own convictions as to “the continuity of the organic and the functional.” As Mapother went on to argue: The results of the policy adopted has been to make the clientele of the Maudsley Hospital more consonant with its dominant theoretical conception of the unity of mental disorder than that of any hospital in the world.30

Mapother gave a clear outline of his anti-Kraeplinian stance in his 1932 lecture on the future of the Maudsley Hospital: The Maudsley Hospital has always stood, as its founder did, for the conception which may be termed the “continuity” of all forms of mental disorder and for the compatibility of treatment within one building of all grades of it. In speaking of the “continuity of mental disorder,” one means that this is a collective term for a medley of different anomalous reactions, and that the ratio in which these various anomalies are inter-mixed even in a single case is infinitely variable and so is the possible intensity of each anomaly. . . . The vogue for such artificial simplicities as classification into neuroses and psychoses is dying out; so is belief that clinical pictures can be isolated and given a descriptive label to which one can relate with any useful constancy a general causation, treatment and course, without the balanced consideration of a multitude of individual factors.31

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Where Mott had argued that the voluntary admissions policy of the Maudsley would serve as an experimental technology supporting longitudinal studies of the sort developed in Kraepelin’s system, Mapother insisted that this experiment had demonstrated the emptiness of the very diagnostic categories that had once structured Kraepelinian classification. In keeping with his latitudinarian nosology, Mapother encouraged an eclectic therapeutic, believing that mental disorder could not be captured in dogmatic systems because of its protean complexity. Instead he encouraged clinical experimentation, arguing that the Maudsley provided a unique opportunity for comparing the rival schools of psychopathology.32 Mapother had himself developed a keen interest in psychotherapy while working with Bernard Hart at Long Grove, yet he was never a convert to Freudian doctrine.33 Working with J. E. Martin in 1921, Mapother became impressed with the pornographic fantasies elicited from a tubercular serving maid and the apparent cure affected by her cathartic abreaction.34 Yet this did not convince him of the merits of the psychoanalytic position. Instead he constructed his own pragmatic interpretation, drawing from a peculiarly English range of sources including James Shaw Bolton, Sigmund Freud, and Rudyard Kipling, to argue that “remote events” such as adolescent trauma or fantasy could never stand as sufficient causes in later cases of mental breakdown. He did not believe that the patient’s “complex” was unconscious, rather it is the “summation of multiple causes, effective in the combination, though inadequate singly.” “It is this,” Mapother claimed, “that renders all controversy between extremists of the physiogenic and the psychogenic schools so futile.”35 Despite his initial tolerance, Mapother became disillusioned by the clinical failure of the talking cures and the increasing dogmatism of the various schools of psychoanalysis. This disillusionment became firmly established during his superintendency of the Maudsley. By 1932, William Sargant could claim that “although [Mapother] had little faith in conventional Freudian, Jungian or other forms of psychotherapy, he encouraged us to go on working even with sometimes obviously second-rate treatments when necessary despite so many dismal failures with them.”36 Following his tour of the United States in 1930, Mapother began to campaign for the foundation of an institute of psychiatry at the Maudsley Hospital.37 Whereas he had once been inspired by the Deutsche Forschungsanstalt für Psychiatrie (DFA) in Munich, Mapother now took East Coast American clinics as his model, citing as examples the Medical Center of New York and the Penn Hospital in Philadelphia.38 In his approach, he adopted a peculiarly English tone, mixing ostentatious cynicism with a quiet pride in the Maudsley’s achievements. Mapother held up the Maudsley’s 70 percent discharge rate as a unique achievement but then went on to deride “the cheap satisfaction to be derived from statistics,” arguing that in the absence of clear clinical criteria over what constituted a cure, such recoveries were only

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as valuable as those apparently achieved by “osteopaths or vendors of patent medicines.”39 Yet his appeal reflected continental ambitions in its demand for a richly endowed institute that would support an integrated educational and research policy and advance the science of psychiatry.40 Mapother’s vision of the institute’s organization was rooted in his pluralist model of psychopathology. He argued that mental disease emerged at the nexus of four crucial factors: the inherited constitution of the individual, the anomalies of personal development (such as adolescence and senility), the residual effect of experience, and the influence of physical facts.41 Thus he proposed that the institute should be headed by a clinical director who would organize the research of workers in subjects as diverse as genetics, endocrinology, anatomy (normal and morbid), psychology, neurophysiology, infectious disease, biochemistry, and human metabolism. This pluralist vision of psychiatry was echoed in Golla’s work. Since taking over the CPL, Golla had pursued the search for the physiological concomitants of mental states that he had first announced in his Croonian Lectures of 1921.42 In these lectures Golla drew upon the James-Lange theory of emotion to argue that every psychic state has its origins in a physical transformation. As evidence he cited his wartime work with Mott at the Fourth London Hospital, where he had used galvanic skin response tests to identify cases of malingering. These tests, Golla believed, had demonstrated the simple physical basis of complex psychic states and provided a model for future psychiatric investigations. Thus, under his guidance, the CPL devoted itself to the discovery of the correlations between physical imbalances and mental disturbances. With his deputies Sidney Mann and Stella Antonovitch, and aided by large number of temporary research workers and seconded psychiatrists from the LCC, Golla produced a wealth of papers on the abnormal chemical, electrical, respiratory, and mechanical processes detected in bodies of the insane.43 For him, the plethsymograph and the electromyograph, the electroencephalograph and the alveometer, all served as forms of artistic media for the creative psychiatrist, allowing him or her to capture and express the insane patient’s pathological interiority at the moment when language failed it: It is the function of the artist to bridge this gap in our social life by presenting his immediate intuition of reality, but we all know how rarely and imperfectly art succeeds. It is precisely for this reason that the studies of those movements which are the exterior signs of states of feeling becomes so important. When our methods of observation become sufficiently perfected we may be able to check by means of these stereotyped forms of reaction the deductions that we draw from the concerted actions, words, and silences of our patients.44

Golla and Mapother’s vision of psychopathology entailed a programmatic set of demands. In its insistence that mental pathology could be traced and corrected through biochemistry and electrophysiology, it militated for the

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same kind of intradisciplinary approach that had been achieved through Rockefeller money at the DFA in Munich.45 Yet their ideal of a coordinated culture of psychiatric research was initially thwarted on two counts. The collapse of the U.S. stock markets led to a temporary suspension of the Rockefeller Foundation’s funding of new institutional projects and the adoption of individual fellowships as an aid to psychiatry.46 At the same time, in June 1932, the main British source of research funding, the Medical Research Council’s Mental Disorders Committee, broke down when senior members, including Golla and Bernard Hart, resigned following the council’s rejection of their fellowship recommendations.47 Despite the fact that following the passage of the 1930 Mental Treatment Act British psychiatry as a whole seemed to be moving toward the Maudsley model, Mapother and Golla found themselves left with the same limited funding and research opportunities with which they had begun their Maudsley careers a decade earlier. However, just as wider political and economic events had thwarted their original ambitions, it was civil upheaval on the continent that was to rescue their vision of psychiatry.

Germany and the Making of an English Psychiatry In the heightened atmosphere of the 1930s, Mapother became aware of the political implications of his intellectual adherence to a tempered skepticism. He saw the growing rejection of the scientific traditions of observation and experiment as analogous to the increase of political irrationalism. Thus in his public lectures, he castigated the new physicists such as Arthur Eddington and E. A. Milne, arguing that their contempt for scientific method was morally equivalent to that of Mussolini’s irrationalism.48 This distrust of political irrationalism gave a new impetus to his critique of Freud. In an excised passage from his unpublished Listerian Lecture, Mapother complained that for “Freud [to] have been given an honorary fellowship of the Royal Society, [is] an event perhaps comparable when the time come[s] to the appointment of the Antichrist to an honorary bishopric.”49 However, it was in continental research into psychiatric eugenics that Mapother saw the clearest example of the corruption of science by political irrationalism. Although both Mapother and his deputy Aubrey Lewis had been firm supporters of eugenic sterilization in 1932, when they gave unequivocal support for the measure before the Brock Committee, by 1933 they seem to have abandoned this position.50 Against their previous insistence that sterilization and castration provided the only reliable methods of eugenic control, Mapother and Lewis now proposed a much more tempered, skeptical, and cautious approach.51 Describing the situation in German psychiatry following the implementation of the “Law for Prevention of

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Offspring with Hereditary Diseases” in July 1933, Lewis claimed that “in the union between politics and science the latter has become the pliant partner and in the writings of several professors . . . the new relationship is celebrated with fervid candour.” As Lewis went on to explain: It is difficult to excuse the geneticist who can declare that “we have a perfectly assured basis for all conceivable political measures dealing with the population” or that with regard to practically all diseases that interest us, because of their frequency, “we know for certain whether they are genetically determined or not and to what extent.” Upon these misstatements and exaggerations and others of older date concerning racial difference, there is being constituted a system of compulsory interference with the liberty to propagate, the total effects of which, though difficult to foresee in detail can scarcely be other than bad. It is fortunate that eugenicists in England have shown more restraint and critical honesty.52

Mapother was to reiterate his deputy’s position. Writing in the Eugenics Review in February 1934, he condemned the confusion of punishment and therapy in the German psychiatric ideas on eugenic sterilization and argued that the moral failure of this politically motivated treatment could be traced back to the myopic nosological certainty of the Kraepelinian system: [Eugenic] compulsion necessarily involves proclaiming certain classes to whom the law must be applied. But definition of such classes in a way that is scientifically defensible is at present impossible. The conditions which in Nazi Germany render a person liable to compulsory sterilization are: mental deficiency, schizophrenia, manic depressive psychosis, Huntingdon’s chorea, deaf mutism, and severe alcoholism.

As Mapother made clear, every one of these conditions could be regarded as an artificial classification: Of mental deficiency it leaps to the eye that it is not a unity, that it includes cases that are of germinal and environmental origin and that sterilization of the latter on truly eugenic ground has no scientific justification whatever. I venture to suggest that in the case of mental disorder exactly the same is true of each of the clinical syndromes, manifestation of which renders the patient liable to compulsory sterilization. We should speak not of schizophrenia but of schizophrenias as we should of the epilepsies. Likewise we should speak not of manic depressive psychosis but of the syntonic syndromes. It is quite certain to my mind that each of these groups—the schizophrenias and the syntonic psychoses—is heterogeneous, including some cases in which an hereditary factor plays a very large part, and others in which it is negligible.53

Although there is no reason to doubt that Mapother and Lewis were genuine in their revulsion at the Nazi racial laws, particularly since Lewis was Jew-

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ish, it is also clear that this protest served a political purpose.54 At one level it served to distance English work in psychiatric genetics from its German counterpart. As Richard Soloway has noted, members of the Eugenics Society in Britain were deeply alarmed at the idea that its policies might be confused with those of Germany’s National Socialists.55 Thus, early in 1933, Carlos Paton Blacker, the Eugenics Society’s general secretary and a close colleague of Mapother’s, had urged his members to take every possible opportunity to distinguish their own campaign from that embodied in the Nazi program.56 Mapother and Lewis’s articles would certainly have served this purpose. Yet on a second level, these rhetorical activities also served to underline the uniqueness and cogency of the Maudsley project for the benefit of courted sponsors—and in particular, for the Rockefeller Foundation.57 In their attempt to develop a distinctive tradition in psychiatry, Mapother and Golla began to celebrate the tentative skepticism that had developed in practice at the Maudsley after Mott’s departure. In their professional writings and their public addresses, they displayed a kind of virtuous uncertainty in which they provided insightful demolitions of their rivals’ positions, yet refused to develop a positive model with which to replace them. In his Presidential Address before the Psychiatric Section of the Royal Society of Medicine in 1934, Mapother drew upon the pragmatic philosophy of William James to underline in his position.58 Utilizing James’s distinction between the “tenderfoot Bostonians” and the “Rocky Mountain toughs,” Mapother attacked the “tender-minded” sciences such as psychoanalysis, arguing that they were predicated upon a form of “animist conceptualism” that confused rhetorical explanations (such as the unconscious) with actual existing entities. In contradistinction to this, he advocated a speculative nominalist psychiatry that would be “tough-minded” in its “retention of [an] awareness that words are just symbols designed to express observed sequences of phenomena (‘whether subjective or objective’).”59 In his suspicion of language and the imposition of “false concreteness” onto abstract concepts, Mapother seemed to ally himself with the philosophy of “neo-Hippocratism,” which was growing in popularity among the medical elites of interwar London. This movement, as David Cantor has convincingly demonstrated, connected the abuse of language with the social fragmentation and social disorder evident in fascist Germany.60 Yet Mapother exhibited none of the hostility toward laboratory science that had fired his patrician contemporaries.61 Rather, he shared with Golla a belief that science could remedy the inadequacies of language while demarcating the proper limits of the clinician’s authority. Golla joined Mapother in this Maudsley project of undermining language and sketching out firm limits to scientific and psychiatric authority. In his Presidential Lecture to the Neurological Section of the Royal Society of Medicine, he had drawn upon the work of the German idealist philosopher,

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Hans Vaihinger, to argue that the psychiatrist and neurophysiologist were simply engaged in the production of “convenient fictions.”62 The conditioned reflexes assiduously investigated by his colleagues were, Golla argued, nothing more than abstractions produced through careful manipulation of the laboratory patient or the experimental animal. A few months later, in his Maudsley Lecture on “Science and Psychiatry,” Golla gave a deeply pessimistic assessment of the limits of medical representation: The continuity of mental processes does not allow of their representation as states of mind, their inter-relatedness does not allow of their separation in terms of psychological atomism. The intuitive and instinctive basis of conduct does not permit of analytical expression. The determination of behaviour by value and purpose negatives mechanical determinism.63

This epistemological skepticism was to become the defining feature of the psychiatric approach of the Maudsley in the interwar years.64 In its stress on modesty and respect for pathological complexity, this approach found its most articulate champion in Mapother’s clinical director, Aubrey Lewis.65 Lewis had trained with Adolf Meyer in Baltimore and with Karl Bonhoeffer in Berlin but refused to ally himself wholeheartedly to either of their schools.66 Instead he devoted himself to the production of cautious clinical descriptions and the exposure of the inherent inadequacies of rival systems.67 Eliot Slater, an assistant medical officer at the Maudsley in the 1930s, provided a fine anecdotal summary of Lewis’s position.68 Recalling his disappointment over Lewis’s failure to reach a conclusion in his synthetic survey of melancholia (published in 1934), Slater remembered: “I told him how persuasive, how convincing I had found his arguments, and could quite well see all the faults, the inconsistencies and insufficiencies advanced by earlier psychiatrists. But I found myself at a loss to see what his own theory was. He told me rather shortly that there was such an abundance of theories that is was not necessary to find a new one or adopt one of the old.”69 As witnesses to the corruption of German psychiatry and as competitors for international funding, the Maudsley staff were forced to reflect upon the nature of their research and define strict limits to their authority. In doing so they developed a peculiarly English style of psychiatry. It was a style that shared, with some of the great figureheads of British science such as C. S. Sherrington and E. D. Adrian, a belief in the modesty of scientific ambition and a dislike of theoretical dogmatism.70 It is clear that this version of liberal Englishness, rooted as it was in the international competition for funding, made a deep impression on the staff of the Rockefeller Foundation. In 1934, Alan Gregg would write to Mapother endorsing his philosophy of nominalism and complaining that “conceptualists” were like “liars who believe what they repeat.”71 A few years later, he reaffirmed his intellectual allegiance to

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Mapother, stating that, “our views on the development of psychiatry were, like icebergs, moved by the same current of belief though blown by different winds of phraseology. And icebergs are 7/8—or is it 8/9—underwater?”72

German Psychiatrists and English Psychiatry From 1933 Mapother was engaged in a Janus-faced operation. At one level he wanted to establish the distinctiveness of the approach to psychiatry at the Maudsley, yet he still maintained a profound admiration for the achievements of his German colleagues. Although many of the hospital’s senior staff (such as Thomas Tennant, Desmond Curran, and Aubrey Lewis) had trained with Adolf Meyer in the United States, and the Maudsley’s catholic approach was indebted to the psychobiology of Meyer, Mapother and Golla still believed that the future of psychiatry lay in the basic research pioneered in the German university clinics.73 Thus the Maudsley maintained close links with Germany until well into the 1930s. Indeed, it was the political disruption in Germany that allowed the hospital to foster these connections, making available a group of established psychiatrists whose careers had been blocked by the Nazis as well as new sources of funding from the Academic Assistance Council (administered by A. V. Hill and William Beveridge), the Medical Research Council, and the Rockefeller Foundation.74 Between 1931 and 1939, at least eleven Central European scholars worked at the Maudsley, while hospital staff such as Aubrey Lewis and Eliot Slater visited Germany for the purpose of research and training.75 It was this mixture of funding, academic connections, and political disruption that allowed the Maudsley to recruit the émigré psychiatrists. In 1931 the Commonwealth Fund, an American mental hygiene charity, had placed two fellowships at the disposal of the Maudsley and the CPL, respectively.76 Golla and Mapother used their first Commonwealth award to recruit Konrad Zucker of Bielefeld, Germany, who worked with both the hospital and the CPL on a variety of subjects including the psychopathology of schizophrenia, cocaine poisoning, and the psychology of shamanism. Zucker was not a refugee and, in his excitement over the rise of the Nazi Party, had initially wanted to abandon his fellowship to return to Germany.77 He was later to take an active part in the T4 “euthanasia” program as chief physician to Carl Schneider at the University of Heidelberg.78 Over the next five years, another ten Germanophone psychiatrists would follow Zucker to the Maudsley. In April 1933, Eric Wittkower, a British subject born to German Jewish parents, arrived from his post as Privatdozent at the Charité Hospital in Berlin.79 Wittkower received immediate support from the Academic Assistance Council before taking up a Medical Research

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Council fellowship at the Maudsley. He shared the CPL members’ interest in the physiological concomitants of mental states and pursued his own research on the usefulness of yoga as a cure for constipation before transferring to the Tavistock on a Halley Stewart Fellowship.80 In 1933, Wittkower was joined by probably the most famous of the émigré psychiatrists, William Mayer-Gross.81 Mayer-Gross had already established strong links with the Maudsley, since Aubrey Lewis had studied under him at Heidelberg in 1928. Thus in September 1933, after the Nazis blocked his accession to the chair at Goettingen, Mayer-Gross wrote to Mapother, inquiring after a possible position. He was offered a Commonwealth Fellowship.82 At the same time, Johann Lange wrote from Breslau, recommending his Privatdozent Eric Guttmann. Guttmann was a Silesian Jew who had trained in neurology at the Charité Hospital in Berlin and in psychiatry at the DFA in Munich.83 In April 1934, he arrived at the Maudsley on a personal fellowship from the Rockefeller Foundation.84 Alfred Meyer, the Jewish professor of neuropathology at the University of Bonn, took up a place at the CPL, where he was funded initially by the Academic Assistance Council and then by the Rockefeller Foundation.85 He was joined in 1933 by Adolf Beck, who had been working at the Marburg Institute of Hygiene.86 After being dismissed (because he was Jewish) and denied citizenship (because of his Czech origins), Beck went to the Pasteur Institute but was soon co-opted by Golla’s Rockefeller-funded research project on the relationship between TB and schizophrenia.87 Four years later they were joined by Walter Spielmeyer’s deputy at the DFA, Felix Plaut, who, helped by the Society for Protection and Learning, took a Rockefeller grant to investigate cases of neurosyphilis for the CPL at the LCC Horton.88 The arrival of the European émigrés was to have widespread institutional and intellectual repercussions. At an institutional level they helped Mapother to realize his long-cherished dream of turning the Maudsley into a worldclass center for teaching and research.89 Within three years of their arrival, the Rockefeller Foundation had agreed to fund the kind of mixed clinical and experimental research group that Mapother had originally requested back in 1931. In 1935, the Foundation granted $45,000 for salaries for five research workers (William Mayer-Gross and Eric Guttmann at the hospital, Alfred Meyer, Adolf Beck, and a Cambridge electrophysiologist, Grey Walter, at the CPL).90 In 1938, this funding was followed by a much larger grant of $127,500 to extend the research.91 Thus through a mixture of foundation grants and historical circumstances a British rival to the DFA emerged. Workers cooperated on a mixed program of clinical and experimental research. Alfred Meyer worked on histopathology and metabolism, Golla and Derek Richter on biochemistry, Beck on infectious disease, Grey Walter and Molly Brazier on electrophysiology, Frederic Bartlett’s pupils on clinical psychology, Alexander Kennedy and Mildred Creak on child psychiatry, Eliot Slater

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on psychiatric genetics, and Mayer-Gross, Lewis, and Guttmann on clinical medicine.92 Both Golla and Mapother believed that their group was extending the boundaries of physiological psychiatry, moving beyond infective and reactive models to one of failed adaptation to the environment.93 However it would be wrong to see the German-speaking émigrés as simply recreating the research conducted at Munich or Berlin within the walls of the Maudsley Hospital. There was no straightforward process of proselytization in which German methods were introduced wholesale by the émigrés. Rather, the process remained closer to that of “emigration-induced scientific change” described by Klaus Fisher and Mitchell Ash in their histories of German psychologists and physicists in the United States.94 The refugees mixed British and German approaches in their investigation of new research topics and in their pursuit of long-standing interests. Thus Wittkower was co-opted by Golla’s investigation of the relationship between respiration and mental imagery and learned to use new techniques such as the Antonovitch plethsymograph, yet still continued his earlier work on the effect of mental agitation on organ function.95 Similarly, Mayer-Gross and Guttmann, supported by Lewis, continued to produce their close phenomenological descriptions of artificially induced pathological states but combined this with a new interest in the effects of chemical and physical treatment.96 Almost forty years later, Eliot Slater would claim that Mapother’s recruitment of the émigré psychiatrists “was one of the most far sighted things he ever did: and it made a historic difference to British psychiatry.”97 Yet it was the peculiar mixture of English skepticism and German thoroughness that was to produce the Maudsley’s long-term legacy. Freed from the schools and traditions that had dominated the German university clinics, the refugees and the hospital staff were able to embark upon a bold period of open-ended clinical experimentation. In the wards of the Maudsley Hospital, Mayer-Gross and Guttmann soon emerged at the forefront of the new trend toward empirical treatment in psychiatry.98 Encouraged by junior staff such as William Sargant, and despite their lack of British medical qualifications, Guttmann and Mayer-Gross embraced the new opportunities for unconstrained experimentation. They used the chemical techniques they had developed in Heidelberg such as benzedrine (to treat depression) and mescalin (to induce artificial psychoses) alongside insulin coma treatments despite the fact that the new methods lacked any kind of overarching rationale or theoretical justification.99 The openness of this approach, Aubrey Lewis believed, had helped to establish the Maudsley’s preeminent position. Writing up a report of a Rockefeller-sponsored tour of European psychiatric institutions, Lewis could claim that in many places where Germany has long been regarded as the European seat of authority in medical, and especially, psychiatric matters, its place was taken

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by England and [the] USA. Many people, I found, were eager to turn to our journals and to get into contact with the men in our centres of activity. . . . I found that the Maudsley Hospital, too, was known in a way that seemed, in view of the recency of its foundation, remarkable.100

The Maudsley, which had been founded in the years leading up to the First World War, would be temporarily disbanded at the outbreak of the Second.101 In the intervening years it had become a very different organization from the one envisioned by Mott in 1907. What had started as the wholesale emulation of German psychiatric ideas and classifications had, by 1939, become a much more practical and optimistic organization. The Maudsley style of psychiatry, which seemed to combine theoretical caution with therapeutic recklessness, offered a peculiarly English—indeed an almost “gung ho”—approach to psychological medicine. Yet its policy of critical pragmatism was to endure in the army treatment of war neuroses and the physical methods of treatment that would dominate psychiatry in postwar Britain.102 It was in the conjunction of diagnostic skepticism and clinical experimentation, born of the Maudsley’s meeting with Germany, that the new biological psychiatry was born.

Notes This research was made possible by a grant-in-aid from the Rockefeller Archive Center, Tarrytown, New York, and greatly assisted by the expertise of Tom Rosenbaum as well as by the generous support of the Wellcome Trust (Grant no. 068387). Patricia Allderidge and Colin Gale provided valuable assistance with the Maudsley Hospital Archive. I should like to thank Leonie Gombrich, Edgar Jones, Michael Neve, Ben Shephard, and the editors for their comments on the argument of this essay. 1. On Mott (1853–1926), see Alfred Meyer, “Frederick Mott, Founder of the Maudsley Laboratories,” British Journal of Psychiatry 122 (1973): 497–516; Constantin von Monakow, “Sir Frederick Mott, K.B.E.: His Life and Work,” in Contributions to Psychiatry, Neurology and Sociology Dedicated to the Late Sir Frederick Mott, ed. John R. Lord (London: H. K. Lewis, 1929): 383–89. On his German models, see Patricia Allderidge, “The Foundation of the Maudsley Hospital,” in 150 Years of British Psychiatry, 1841–1991, ed. German E. Berrios and Hugh L. Freeman (London: Gaskell, 1991), 84. 2. Frederick W. Mott, “Preface,” Archives of Neurology 3 (1907): vi. Mott attributes these views to one Dr. Paton but there is no corresponding reference in the cited number of the British Medical Journal. Cf. Stewart Paton, Psychiatry (Philadelphia: J. B. Lippincott, 1905), 2. 3. Mott’s campaign for receiving houses begins in 1903. See Mott, “Preface,” Annals of Neurology 2 (1903): xiii. On the Kraepelinian model and its uptake in England, see the essays by Paul Hoff, Eric Engstrom, German Berrios, and Renate Hauser in A History of Clinical Psychiatry, ed. German Berrios and Roy Porter (London: Athlone, 1996), chap. 10; German Berrios and Renate Hauser, “The Early Development

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of Kraepelin’s Ideas: A Conceptual History,” Psychological Medicine 18 (1988): 813–21; R. M. Ion and M. D. Beer, “The British Reaction to Dementia Praecox,” History of Psychiatry 13, no. 3 (2002): 285–304, 419–31. 4. Mott, “Preface,” v–vi. (For a later restatement of this position, see Mott, “Is Insanity on the Increase,” Sociological Review 6, no. 1 (1913): 1–28.) The preface is quoted in part in Mott, “The Second Maudsley Lecture,” Journal of Mental Science 67 (1921): 319–39, quote on p. 320. 5. On the hospital as a technology for visualizing individual diseases, see Michel Foucault, “The Politics of Health in the Eighteenth Century,” in Power/Knowledge: Selected Interviews and Other Writings, 1972–77, ed. Colin Gordon (Brighton: Harvester, 1980); Ruth Leys, “Types of One: Adolf Meyer’s Life Chart and the Representation of Individuality,” Representations 34 (Spring 1991): 1–28; Nicholas Rose, “Medicine, History and the Present,” in Reassessing Foucault: Medicine, History and the Body, ed. Colin Jones and Roy Porter (London: Routledge, 1994), 48–72. 6. Allderidge, “The Foundation of the Maudsley Hospital,” 79–88; Alexander Walk, “Medico-Psychologists, Maudsley and The Maudsley,” British Journal of Psychiatry 128 (1976): 28–30. On Maudsley (1835–1918), see Andrew Scull, Charlotte Mackenzie, and Andrew Harvey, Masters of Bedlam: The Transformations of the Mad-Doctoring Trade (Princeton: Princeton University Press, 1996), chap. 8, esp. 263–67. For a statement of Maudsley’s views, see Henry Maudsley, “A Mental Hospital: Its Aims and Uses,” Annals of Neurology 4 (1909): 1–12. For a fine overview of the debates surrounding the hospital’s establishment, see Edgar Jones, Shahina Rahman, and Robin Woolven, “The Maudsley Hospital: Design and Strategic Direction, 1923–39,” Medical History 51 (2007): 357–78. 7. Allderidge, “The Foundation of the Maudsley Hospital,” 86–87. Although Cecil Harmsworth’s 1915 Mental Treatment Bill had run out of parliamentary time, a clause in the 1915 London County Council Act (for parks, etc.) granted the Maudsley special dispensation to accept voluntary patients. See Clive Unsworth, The Politics of Mental Health Legislation (Oxford: Oxford University Press, 1987), 177–79. 8. “Psychological and Psychiatrical Clinics in Germany,” British Medical Journal (20 June 1908): 1534–37; Bedford Pierce, “Discussion on the Treatment of Incipient Insanity,” British Medical Journal (19 September 1908): 818–21. 9. R. G. Rows, “A Report on the Conditions of the Lunacy Service and the Teaching of Psychiatric Medicine in Germany,” Journal of Mental Science 58 (October 1912): 610–22. On Rows, see Ben Shepherd, “‘The Early Treatment of Mental Disorders’: R. G. Rows and Maghull, 1914–18,” in 150 Years of British Psychiatry, Volume II: The Aftermath, ed. Hugh L. Freeman and German E. Berrios (London: Athlone, 1996), 434–64. 10. “Report of the Committee re Status of British Psychiatry and of Medical Officers,” Journal of Mental Science 60 (1914): 667–73. C. Hubert Bond, “The Position of Psychiatry and the Role of General Hospitals in its Improvement,” Journal of Mental Science 61 (1915): 1–17. For the debate over psychiatric education, see John L. Crammer, “Training and Education in British Psychiatry, 1770–1970,” in 150 Years of British Psychiatry, Volume II, 209–42. On Craig, see H. C. Cameron, “Sir Maurice Craig,” Guys Hospital Reports 85 (1935): 251–57. 11. Bedford Pierce, “Absence of Proper Facilities for the Treatment of Mental Disorders in their Early Stages,” British Medical Journal (8 January 1916): 41–44; L. A.

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Weatherly, “The Work of Registered Hospitals for the Insane,” The Lancet (5 August 1916): 248. 12. Shell Shock and Its Lessons (Manchester: Manchester University Press, 1919), 84–85. On T. H. Pear, see Alan Costall, “Pear and his Peers,” in Psychology in Britain: Historical Essays and Personal Reflections, ed. G. Bunn, A. D. Lovie, and G. Richards (Leicester: British Psychological Society, 2001), 188–205. 13. Mott, “The Second Maudsley Lecture,” 321. 14. For Mott’s work on shell shock, see Mott, “The Effects of High Explosive on the Central Nervous System,” The Lancet 1 (1916): 331–38, 441–49, 545–53; “Special Discussion on Shell Shock without Visible Signs of Injury,” Proceedings of the Royal Society of Medicine (1916), 1–44; “Two Lectures on War Psycho-Neurosis,” The Lancet 1 (1918): 127–29; 169–72. For an overview, see Ben Shephard, A War of Nerves (London: Jonathan Cape, 2000), 110–13. 15. Mott, “The Second Maudsley Lecture,” 321–22. 16. W. J. Collins, “Preface,” Archives of Neurology 1 (1900): vii–xii. 17. Mott, “The Second Maudsley Lecture,” 327; von Monakow, “Mott,” 386–87. On Kraepelin’s diagnostic card system, see Matthias M. Weber and Eric J. Engstrom, “Kraepelin’s ‘Diagnostic Cards’: The Confluence of Clinical Research and Preconceived Categories,” History of Psychiatry 8 (1997): 375–85. 18. On the law of anticipation, see Mott, “The Inborn Factors of Nervous and Mental Disease,” Brain 34 (1911): 1–101; “The Neuropathic Inheritance,” Journal of Mental Science (1913): 79–98. On the wider acceptance of Mott’s theory, see “The Investigation of Some of the Causes of Insanity,” Journal of Mental Science 71 (1925): 631–47; “Chadwick Lecture: Heredity in Relation to Mental Disease and Mental Deficiency,” British Medical Journal (1926): 1023–26; von Monakow, “Sir Frederick Mott, K.B.E.: His Life and Work,” 387; Meyer, “Frederick Mott, Founder of the Maudsley Laboratories,” 507. 19. Mott, “The Second Maudsley Lecture,” 325; Mott, “The Application of Physiology and Pathology to the Study of the Mind in Health and Disease,” Proceedings of the Royal Society of Medicine 8 (1915): 1–16. Both von Monakow and Meyer provide good analyses of Mott’s somaticism. 20. Mott, “Normal and Morbid Conditions of the Testes from Birth to Old Age in 100 Asylum and Hospital Cases,” British Medical Journal (22 November 1919): 655–59; (29 November 19): 698–700; (6 December 1919): 737–42; “The Psychopathology of Puberty and Adolescence,” Journal of Mental Science 67 (1921): 280–318; “The Reproductive Organs in Relation to Mental Disorder,” British Medical Journal (25 March 1922): 463–66; “The Condition of Sex Organs in Dementia Praecox,” Encephale 18 (1923): 73–85. 21. Mott, “The Genetic Origin of Dementia Praecox,” Journal of Mental Science 68 (1922): 345–47. 22. E. Kraepelin, Dementia Praecox and Paraphrenia, trans. from the 8th German ed. of the Lehrbuch der Psychiatrie 3, pt. 2 by Mary Barclay, ed. G. M. Robertson (Edinburgh: E. S. Livingstone, 1919). 23. Mott’s classic work on neuropathology was his 1900 Croonian Lectures, published as The Croonian Lectures on the Degeneration of the Neurone (1900) (London: Bale and Danielson, 1900). For an overview of his work on pathological neurohistology, see Meyer, “Frederick Mott, Founder of the Maudsley Laboratories,” 502–3.

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24. On Mapother (1881–1940), see Aubrey Lewis, “Edward Mapother and the Making of the Maudsley Hospital: The First Mapother Lecture Delivered at the Institute of Psychiatry, 26 March 1969,” in The Later Papers of Sir Aubrey Lewis (Oxford: Oxford University Press, 1979), 135–52; Rhodri Hayward, “Mapother, Edward,” in Oxford Dictionary of National Biography, ed. H. C. G. Matthew and Brian Harrison (Oxford: Oxford University Press, 2004), 36: 587–88. For his interest in boxing and wrestling, see C. P. Blacker, “The Sportsman,” Bethlem Maudsley Hospital Gazette 3, no. 8 (1960): 15–17. 25. On Golla (1877–1968), see Jonathan Bird, “The Father of Psychophysiology—Professor F. L. Golla and the Burden Neurological Institute,” in 150 Years of British Psychiatry, Volume II, 500–16; Rhodri Hayward, “Golla, Frederick Lucien,” in Oxford Dictionary of National Biography, 22: 705–6. 26. Desmond Curran, “Mapother, the Man,” Bethlem Maudsley Hospital Gazette 3, no. 7 (1960): 4–5. 27. In their stress on the psychobiological unity of the individual, Golla and Mapother were extremely close to the position developed by Adolf Meyer, although they laid greater stress on the physiological origins of mental disorder. See Michael Gelder, “Adolf Meyer and His Influence on British Psychiatry,” in 150 Years of British Psychiatry, 1841–1991, 419–35. 28. Mapother, “Discussion on Manic-depressive Psychosis,” British Medical Journal 2 (1926): 872–79. For commentaries on this debate, see German Berrios, “Mood Disorders: Clinical Section” in A History of Clinical Psychiatry, ed. German Berrios and Roy Porter (London: Athlone, 1995), 398–99; German Berrios, The History of Mental Symptoms: Descriptive Psychopathology since the Nineteenth Century (Cambridge: Cambridge University Press, 1996), 317–18. 29. Mapother, “Discussion on Manic-depressive Psychosis,” 877 (for polemics with Buzzard), 878 (for polemics with Ross). On Buzzard (1871–1945), see Munk’s Roll, Volume IV, Lives of the Fellows of the Royal College of Physicians of London, 1826–1925, comp. G. H. Brown (London: Royal College of Physicians, 1955), 473–74. On Ross (1875–1941), see Munk’s Roll, Volume V, Lives of the Fellows of the Royal College of Physicians of London, 1926–1965, ed. Richard R. Trail (London: Royal College of Physicians, 1968), 359–60. On the Maudsley’s admissions policy, see Edgar Jones, Shahina Rahman, and Robin Woolven, “The Maudsley Hospital: Design and Strategic Direction, 1923–1939,” Medical History 51, no. 3 (2007): 357–78. 30. Mapother, “An Appeal for the Endowment of an Institute of Psychiatry and Psychopathology at the Maudsley Hospital and the Central Pathological Laboratory: March 1931” (Bethlem Royal Hospital Archive, Mapother Box 1), 3. Copy also held at the Rockefeller Archive Center, Sleepy Hollow, New York (hereafter RAC), folder 263, box 20, series 401A, Record Group (hereafter RG) 1.1. 31. Mapother, Maudsley Hospital: Medical Superintendent’s Report. Period from 1 January 1927 to 31 December 1931 (London: London County Council, 1932), 22. 32. Mapother, “An Appeal for the Endowment,” 15. 33. Lewis, “Edward Mapother and the Making of the Maudsley Hospital,” 136– 37. On Bernard Hart (1879–1966), see Munk’s Roll, Volume VI, ed. Gordon Wolstenholme (Oxford: IRL Press Limited, 1982), 226–27. 34. Edward Mapother and J. E. Martin, “Fantasies of Childhood and Adolescence as a Source of Delusions,” Journal of Mental Science 68 (1922): 33–48. On Martin, deputy

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medical superintendent at Long Grove, see Medical Directory (London: Churchill, 1939), 949. 35. Mapother and Martin, “Fantasies of Childhood and Adolescence,” 41. 36. William Sargant, The Unquiet Mind: An Autobiography (Heinemann, 1967; London: Pan Books, 1971), 60. Citation is to the Pan Books edition. For more on Mapother’s attitude to psychoanalysis, see Malcolm Pines, “The Development of the Psychodynamic Movement,” in 150 Years of British Psychiatry, 1841–1991, 222–25. The often quoted idea of Mapother’s irrational hatred of psychoanalysis and the Tavistock, put forward by H. V. Dicks in Fifty Years of the Tavistock Clinic (London: Routledge, 1970), 60–63, is a myth and needs to be contested. For Mapother’s considered position on the Tavistock, see his letters to J. R. Rees, Mapother to Alan Gregg (24 December 1930) in Bethlem Royal Hospital Archive, Mapother Box 1. 37. For the appeal see Mapother, “An Appeal for the Endowment,” 31; Mapother, “Impressions of Psychiatry in America,” The Lancet 218 (1930): 848–52. 38. Mapother, “Research in Psychiatry: Maudsley Hospital (March 1931),” RAC, folder 247, box 18, series 104A, RG 1.1. 39. Mapother, “An Appeal for the Endowment,” 3. 40. On Mapother’s admiration for the German system, see his articles “Die Münchner psychiatrische Klinik,” Allgemeine Zeitschrift für Psychiatrie 84 (1926): 321– 29; “Emil Kraepelin,” Journal of Mental Science 73 (1927): 509–15. 41. Mapother, “An Appeal for the Endowment,” 4. 42. F. L. Golla, “The Objective Study of Neurosis,” The Lancet (16 July 1921): 115–22; (30 July 1921): 215–21; (6 August 1921): 265–70; (20 August 1921): 373–79. 43. F. L. Golla and S. Antonovich, “The Respiratory Rhythm and Its Realtion to the Mechanism of Thought,” Brain 52 (1929): 491–510; F. L. Golla and S. Antonovich, “The Relation of the Muscular Tonus and the Patellar Reflex to Mental Work,” Journal of Mental Science 75 (1929): 234–41; F. L. Golla and L. C. Cook, “An Isometric Study of the Human Knee and Ankle Relfexes,” The Mott Memorial (1929): 45–56; F. L. Golla and J. Hettwer, “A Study of the Electromyograms of Voluntary Movement,” Brain 47 (1924): 57–69; F. L. Golla, S. A. Mann, and R. G. B. Marsh, “The Respiratory Regulation in Psychotic Subjects,” Journal of Mental Science 74 (1928): 443–53. For other examples, see the reprints in the Archives of Neurology and Psychiatry, vols. 8, 9, and 10. 44. Golla, “The Objective Study of Neurosis,” The Lancet (16 July 1921): 116. For the background to this position, see Otniel E. Dror, “The Affect of Experiment: The Turn to Emotions on Anglo-American Physiology, 1900–1940,” Isis 90 (1999): 205–37. On the relationship between electrophysiology and artistic production, see Cornelius Borck, Hirnströme: Eine Kulturgeschichte der Elektroenzephalographie (Göttingen: Wallstein, 2005); Borck, “Schreibende Gehirne,” in Psychographien, ed. Cornelius Borck and Armin Schäfer (Zurich: Diaphanes 2005), 89–110. 45. M. M. Weber, “Ein Forschunginstitut für Psychiatrie. Die Entwicklung der deutschen Forschungsanstalt für Psychiatrie München 1918–1945,” Sudhoffs Archiv 75 (1991): 74–89. 46. Gregg to Mapother, 11 December 1931, in BRHA Mapother Box 1. Copy in RAC, folder 248, box 18, series 401A, RG 1.1. See also the notes on the staff conference on 16 March 1931 held in folder 247. K. Angel has argued that Gregg’s cited reason of failing U.S. investments was simply a whitewash in order to cover

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the Foundation’s skepticism over Mapother’s proposals. See “Defining Psychiatry: Aubrey Lewis’s 1938 Report and the Rockefeller Foundation,” in European Psychiatry on the Eve of War: Aubrey Lewis, the Maudsley Hospital, and the Rockefeller Foundation in the 1930s, ed. K. Angel, E. Jones, and M. Neve, Medical History Supplement 22 (London: Wellcome Trust Centre for the History of Medicine at University College London, 2003): 39–41. 47. Public Record Office (PRO) FD 1: Files 1398 and 1399. 48. Edward Mapother, “Presidential Address to the Listerian Society: Kings College Hospital 1937,” MS, 4. BRHA Mapother Box 2. On Eddington (1882–1944) and his irrationalism, see L. P. Jacks, Arthur Eddington: Scientist and Mystic (Cambridge: Cambridge University Press, 1948). On E. A. Milne (1896–1950), see A. J. Harder, “E. A. Milne, Scientific Revolutions and the Growth of Knowledge,” Annals of Science 31 (1974): 351–63. 49. “Listerian Lecture: Kings College Hospital, 1937,” MS. BRHA Mapother Box 2. 50. On the Brock Committee, see Mathew Thomson, The Problem of Mental Deificiency (Oxford: Clarendon Press, 1988), 185–86. Aubrey J. Lewis and Edward Mapother, “Uses of Sterilisation in Inherited Mental Disorder,” BRHA Mapother Box 1. On Aubrey Lewis, see Michael Shepherd, A Representative Psychiatrist: The Career, Contributions and Legacies of Sir Aubrey Lewis. Psychological Medicine, Monograph Supplement 10 (Cambridge: Cambridge University Press, 1986). On the common approach of Mapother and Lewis, see Edgar Jones, “Aubrey Lewis, Edward Mapother and the Maudsley,” in European Psychiatry on the Eve of War, 3–38. 51. In the Brock Committee Memorandum they had argued: “It is desirable that the propagation of people with inherited mental disorders should stop. Between the methods, segregation, contraception, abortion, sterilization, castration it is not necessary to make a general judgment” before going on to argue that only sterilization and castration had the necessary qualities of “certainty and permanence.” Aubrey Lewis and Edward Mapother, “Uses of Sterilization in Inherited Mental Disorder” (n. d.), BRHA Mapother Box 2. A year later, in an article for lay audiences, Lewis had given a favorable assessment of the German research but insisted that the choice over reproduction must remain with the informed patient. See “The Inheritance of Mental Disorder,” in The Chances of Morbid Inheritance, ed. C. P. Blacker (London: H. K. Lewis, 1934), 86–131, esp. 130–31. 52. [Aubrey Lewis], “Eugenics in Germany,” The Lancet (5 August 1933): 297–8. On Lewis’s authorship of this anonymous editorial, see Michael Shepherd, “The Legacies of Aubrey Lewis” in Conceptual Issues in Psychological Medicine, 2nd ed. (London: Routledge, 1990), 139–41. For a fuller exposition of Lewis’s position, see “German Eugenic Legislation,” Eugenics Review 26 (1934): 183–91. For the German background, see Paul Weindling, Health, Race and German Politics between National Unification and Nazism (Cambridge, MA: Harvard University Press, 1988), 522–34; M. Burleigh and Wolfgang Wipperman, The Racial State: Germany 1933–45 (Cambridge: Cambridge University Press, 1991). For changing international assessments of Rüdin’s work, see Volker Roelcke, “Programm und Praxis der psychiatrischen Genetik an der deutschen Forschungsanstalt für Psychiatrie unter Ernst Rüdin: Zum Verhältnis von Wissenschaft, Politik und Rasse-Begriff vor und nach 1933,” Medizinhistorisches Journal 37 (2002): 21–56.

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53. Edward Mapother, “Safeguards in Eugenic Sterilization,” Eugenics Review 26, no. 1 (1934–35): 17–18. 54. On the complexity of Lewis’s Jewish identity, see C. Hilton, “A Jewish Contribution to British Psychiatry: Edward Mapother, Aubrey Lewis and their Jewish and Refugee Colleagues at the Bethlem and Maudsley Hospital and Institute of Psychiatry, 1933–66,” Jewish Historical Studies 41 (2007): 209–29. 55. Richard Soloway, Demography and Degeneration: Eugenics and the Declining Birthrate in Twentieth-Century Britain, 2d ed. (Chapel Hill: University of North Carolina Press, 1995), 301–2. 56. On Blacker, see Munk’s Roll Volume VI, 49–50; Kevles, In the Name of Eugenics (Cambridge, MA: Harvard University Press, 1995), 170–72. Interestingly, Blacker’s actions seem to have been prompted by Aubrey Lewis, who complained to him in July 1933 that new German laws were “a queer mixture of orthodox eugenics and racial hate stuff, undisguised.” See Soloway, Demography. On Blacker’s relationship with Mapother, see CMAC/PP/CPB/D.1. 57. On the Rockefeller Foundation, see Robert Kohler, “A Policy for the Advancement of Science: The Rockefeller Foundation, 1924–29,” Minerva 16 (1978): 480–515; Ilana Löwy and Patrick Zylberman, “Medicine as a Social Instrument: Rockefeller Foundation, 1913–45,” Studies in History and Philosophy of Science Part C: Studies in History and Philosophy of Biological and Biomedical Sciences 31, no. 3 (2000): 365–79; Paul Weindling, “The Rockefeller Foundation and the German Biomedical Sciences, 1920–40: From Educational Philanthropy to International Science Policy,” in Science, Politics and the Public Good: Essays in Honour of Margaret Gowing, ed. Nicholas Rupke (Basingstoke: Macmillan, 1988), 292–94. 58. William James, “The Present Dilemma in Philosophy” [1907], in Pragmatism: In Focus, ed. Doris Olin (London: Routledge, 1992), 26–28. 59. “Tough or Tender. A Plea for Nominalism in Psychiatry” [RSM Psychiatry Section—President’s Address], Proceedings of the Royal Society of Medicine 27, no. 7 (1934): 1687–1712. 60. David Cantor, “The Name and the Word: Neo-Hippocratism and Language in Interwar Britain,” in Reinventing Hippocrates, ed. David Cantor (Aldershot: Ashgate, 2002), 280–301, esp. 284–88. 61. Christopher Lawrence, “A Tale of Two Sciences: Beside and Bench in Twentieth-Century Britain,” Medical History 43 (1999): 421–49; “Still Incommunicable: Clinical Holists and Medical Knowledge in Interwar Britain,” in Greater than the Parts: Holism in Biomedicine, 1920–50, ed. C. Lawrence and G. Weisz (Oxford: Oxford University Press, 1998), 94–111. 62. “The Nervous System and the Organic Whole” [President’s Address of the Royal Society of Medicine], Proceedings of the Royal Society of Medicine 30 (1937): 579– 98. Hans Vaihinger, The Philosophy of As If, trans. C. K. Ogden (London: Routledge, 1924). Cf. Golla, “Some Recent Work on the Pathology of Schizophrenia,” Proceedings of the Royal Society of Medicine 22 (July 1929): 31–37, repr. Annals of Psychiatry and Neurology 10 (1931): 1–10, esp. 7. Citations are to the 1931 reprint. 63. “The Eighteenth Maudsley Lecture: Science and Psychiatry,” Journal of Mental Science 84 (1938): 20. 64. Thus some of the most important papers produced by the CPL undermined the traditional tenets of the group’s research. See Irene Yates and John C.

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Batt, “Experimental Error in the Enumeration of Leucocytes and its Application to the Haemoclastic Crisis,” Journal of Mental Science 78 (1932): 160–73; A. S. Patterson, “The So-Called Law of Anticipation in Mental Disease,” Journal of Neurology and Psychopathology 13 (1933): 193–210. 65. Lewis had been appointed consultant in 1932 and was promoted to clinical director in 1936. 66. On Bonhoeffer, see K. J. Neumarker, “Karl Bonhoeffer and the Concept of the Symptomatic Psychoses,” History of Psychiatry 12 (2001): 213–26. 67. For a basic statement of Mapother and Lewis’s position, which emphasises the complexity of psychiatric assessment, see their entry “Psychological Medicine,” in A Textbook of the Practice of Medicine, 5th ed., ed. F. W. Price (London: Oxford University Press, 1937): 1798–1883, esp. 1800–1801. 68. On Slater (1904–83), see Irving Gottesman and Peter McGuffin, “Eliot Slater and the British of Psychiatric Genetics in Great Britain,” in 150 Years of British Psychiatry, Volume II, 537–48. 69. Eliot Slater, “Autiobiographical Sketch,” in Man, Mind and Heredity, ed. James Shields and Irving Gottesman (Baltimore: The Johns Hopkins University Press, 1971), 15; see also Michael Gelder, “Sir Aubrey Lewis’s Contributions to Psychiatry,” British Journal of Psychiatry 128 (1976): 31–35. For Lewis’s work on melancholia, see “Melancholia: A Historical Review,” Journal of Mental Science 80 (1934): 1–42; “Melancholia: Prognostic Study and Case-material,” Journal of Mental Science 82 (1936): 488–558. 70. On this idea of English “style,” see Robert Colls, “Englishness and Political Culture,” in Englishness, Politics and Culture, ed. R. Colls and P. Doss (London: Croom Helm, 1986), 29–61; Stefan Collini, “The Idea of Character,” Public Moralists: Political Thought and Intellectual Life in Britain, 1850–1930 (Oxford: Clarendon Press, 1991), chap. 3. For scientific examples, see Christopher Lawrence and A. K. Mayer, Regenerating England: Science, Medicine and Culture in Inter-War England (Amsterdam: Rodopi, 2000); Roger Smith, “The Embodiment of Value: C. S. Sherrington and the Cultivation of Science,” British Journal of the History of Science 31 (2000): 283–312. 71. Alan Gregg to Mapother (17 December 1934). RAC, folder 250, box 18, series 401A, RG 1.1. 72. Alan Gregg to Mapother (3 September 1936). RAC, folder 250, box 18, series 401A, RG 1.1. 73. By the late 1930s, Golla and Mapother seem to have grown wary of Adolf Meyer’s all-inclusive approach. See Sargant to Mapother (30 March 1939), BRHA Mapother Box 2. On Tennant (1900–1962), see British Medical Journal 1 (1962): 489– 90; The Lancet 1 (1962): 331–32. On Curran (1903–85), see The Lancet 2 (1985): 903. 74. On the role of the Academic Assistance Council, see Paul Weindling, “The Contribution of Central European Jews to Medical Science and Practice in Britain, the 1930s to the 1950s,” in Second Chance: Two Centuries of German Speaking Jews in the United Kingdom, ed. Werner Mosse et al. (Tübingen: J. C. Mohr, 1991), 243–54. On the Rockefeller Foundation and refugee scientists, see Paul Weindling, “An Overloaded Ark? The Rockefeller Foundation and Refugee Medical Scientists,” Studies in History and Philosophy of Science Part C: Studies in History and Philosophy of Biological and Biomedical Sciences 31, no. 3 (2000): 477–89. For a prosopography of the forced emigration, see Uwe Henrik Peters, “The Emigration of German Psychiatrists to Britain,” in 150 Years of British Psychiatry, Volume II, 565–80; Peters, “Emigration deutscher

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Psychiater nach England. Teil 1: England als Exilland fuer Psychiater,” Fortschritte der Neurologie, Psychiatrie 64 (May 1996): 161–67; for the impact of these emigrants, see the chapter by Paul Weindling in this volume. 75. These German scholars were Adolf Beck, Eric Guttmann, Alfred Meyer, William Mayer-Gross, Wilhelm Peters, Felix Plaut, Eric Wittkower, and Konrad Zucker. This broad estimate includes nonrefugee scholars (Konrad Zucker), volunteers (A. H. Peters), and the German wives of staff members who carried out temporary work, including Hilda Stoessiger (wife of Aubrey Lewis) and Elizabeth Beck (wife of Adolf Beck). 76. On the Commonwealth Foundation, see A. McGhee Harvey and Susan Abrams, For the Welfare of Mankind: The Commonwealth Fund and American Medicine (Baltimore: The Johns Hopkins University Press, 1986). 77. William Mayer-Gross, “Recollections of a Refugee,” Bethlem Maudsley Hospital Gazette 3, no. 8 (September 1960): 7–8. 78. Information from Volker Roelcke. 79. On Wittkower (1899–1983), see Raymond H. Prince, “Transcultural Experiences and Canadian Perspectives,” Canadian Journal of Psychiatry 45 (2000): 431–37; H. Murphy, “In Memoriam: Eric D. Wittkower (1899–1983),” Transcultural Psychiatric Research Review 20 (1983): 81–86. 80. E. Wittkower and K. Dhahan, “Über Behandlung chronischer funktioneller Obstipationen mit Methoden der Yoga-praxis,” Deutsche Medizinische Wochenschrift 59 (1933): 284–85; Dicks, Fifty Years of the Tavistock Clinic, 76–78. 81. On Mayer-Gross (1889–1961), see Munk’s Roll, Volume V, 275–78; Aubrey Lewis, “William Mayer-Gross: An Appreciation,” Psychological Medicine 7 (1977): 11– 18; Hugh Freeman, “Gross, William Mayer (1889–1961),” Oxford Dictionary of National Biography (Oxford: Oxford University Press, 2004), http://www.oxforddnb.cm.libsys. wellcome.ac.uk:80/view/article/51731/ (accessed 13 October 2008). 82. Letters between Mayer-Gross (3 August 1933) and Mapother (13 September 1933) in BRHA Mapother Box 14C/12/4. 83. Johann Lange to Mapother (12 August 1933) in BRHA Mapother Box 14C/12/4. 84. On Eric Guttmann (1896–1948), see “Eric Guttmann,” The Lancet 1 (1948): 694, 733; “Eric Guttmann,” British Medical Journal 1 (1948): 908, 957. On his grant, see the correspondence between Gregg and Mapother, RAC, folder 249, box 19, series 401A, RG 1.1. 85. See the correspondence on Meyer between Walter Spielmeyer and R. A. Lambert, RAC, folder 248, box 18, series 401A, RG 1.1. On Meyer (1895–1990), see J. B. Cavanagh, “Alfred Meyer,” Neuropathology and Applied Neurobiology 17 (February 1991): 83–87. 86. “Adolf Beck, MD, FRCPATH,” British Medical Journal 292 (1986): 1210; The Lancet 1 (1986): 692 87. Alan Gregg, “Diary 2 June 1934,” RAC, folder 249, box 19, series 401A, RG 1.1. 88. On Plaut (1877–1940), see Deutsche Biographische Enzyklopadie (DBE) 7: 691. RAC, folder 242, box 18, series 401A, RG 1.1. Grant in Aid, no. 30, 25 August 1939. 89. Alan Gregg, “Diary (2 June 1934)” RAC, folder 248, box 18, series 401A, RG 1.1.

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90. RAC, folder 250, box 19, series 401A, RG 1.1, esp. D. P. O’Brien to Alan Gregg, “Aid to Psychiatry at the Maudsley (6/3/35).” On Grey Walter (1910–76), see Rhodri Hayward, “The Tortoise and the Love Machine: Grey Walter and the Politics of Electroencephalography,” Science in Context 14, no. 4 (2001): 615–42. 91. RAC, folder 255, box 19, series 401A, RG 1.1 92. D. P. O.’Brien to Alan Gregg, “Maudsley Hospital: Continued Aid (12/1/38),” RAC, folder 254 and 255, box 19, series 401A, RG 1.1. 93. RAC, folder 250, box 19, series 401A, RG 1.1. 94. See essays in Mitchell G. Ash and Alfons Sollner, Forced Migration and Scientific Change: Émigré German-Speaking Scientists and Scholars after 1933 (Washington: German Historical Institute and Cambridge University Press, 1996). 95. Report of Dr. F. L. Golla, Pathologist to the London County Mental Hospitals and Director of the Central Pathological Laboratory, 1933–34. RAC, folder 250, box 19, series 401A, RG 1.1. For work directed by Golla, see “Further Studies in the Respiration of Psychotic Patients,” Journal of Mental Science 80 (1934): 692–704. For the continuation of his Berlin research, see “Studies on the Influence of Emotions on the Functions of the Organs,” Journal of Mental Science 81 (1935): 533–682; Einfluss der Gemuetsbewegungen auf den Koerper (Vienna and Leipzig: Semsein Verlag, 1936). 96. W. Mayer-Gross and Eliot Slater, “Affective Psychoses,” British Encyclopaedia of Medical Practice 10 (1938): 267–91. 97. Greg Wilkinson, ed., Talking about Psychiatry (London: Gaskell and the Royal College of Psychiatry, 1997): 7. 98. Desmond Curran and Eric Guttmann, Psychological Medicine (Edinburgh: E. S. Livingstone, 1943). 99. Sargant, Unquiet Mind, 68; W. S. Maclay and Eric Guttmann, “Mescalin and Depersonalization: Therapeutic Experiments,” Journal of Neurology and Psychopathology 16 (1936): 193–212. Sargant and Guttmann, “Observations on Benzedrine,” British Medical Journal 1 (1937): 1013–15. 100. [Aubrey Lewis], “Aubrey Lewis’s Introduction to His Report,” in European Psychiatry on the Eve of War, 57, 146. 101. Shephard, A War of Nerves, chaps. 14–18; Claire Hilton, “Mill Hill Emergency Hospital, 1939–45,” Psychiatric Bulletin 30 (2006): 106–8. 102. William Sargant and Eliot Slater, An Introduction to Physical Methods of Treatment in Psychiatry, 2d ed. (Edinburgh: E. S. Livingstone, 1948); Edward Shorter, A History of Psychiatry: From the Age of the Asylum to the Age of Prozac (New York: John Wiley & Sons, 1997), chap. 6.

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Chapter Five

Patterns in Transmitting German Psychiatry to the United States Smith Ely Jelliffe and the Impact of World War I John C. Burnham To see how the transnational history of psychiatry worked out in concrete terms, perhaps no better example exists than the American neurologist, psychiatrist, and psychoanalyst Smith Ely Jelliffe (1866–1945).1 In his medical and publishing activities, Jelliffe exemplified patterns that marked the ways in which Americans reacted to German psychiatry in the first four decades of the twentieth century.2 Jelliffe is of special interest because he was both a key observer and an actor in the transfer of medical findings between the Old World and the New. As late as 1946, a colleague described Jelliffe and Adolf Meyer as the two links “between the psychiatrists of Europe and the United States.”3 Jelliffe’s activities, moreover, furnish striking evidence of the fundamental change in knowledge transfer that followed World War I—a change that historians have heretofore appreciated but little. One general development in international relationships marked the twentieth century: increasing American independence and insularity in the field of medicine. In the nineteenth century, American medicine was overwhelmingly derivative, transmitted largely from France and then from Germany—and the continental material was often conveyed through British publications.4 By the middle of the twentieth century, however, American physicians appeared to know or care little about medical developments elsewhere in the world. It is this transition from external dependence to self-sustaining independence and extraordinary provincialism that Jelliffe exemplified or inadvertently highlighted in his publishing endeavors. Figures 5.1 and 5.2, showing American medical journal citations of materials in French and German, illustrate the secular change to provincialism. For German-language citations, the figures are high to start with, reflecting the

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Figure 5.1. Long-term trends in the proportion of citations of French and German medical publications in sample years of the Journal of the American Medical Association, 1883–1983.

Figure 5.2. Long-term trends apparent in the proportion of citations of French and German medical publications in sample years of the New England Journal of Medicine, 1871–1981.

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deep influence of German medicine on American physicians, fifteen thousand of whom studied in Germany and Austria between 1880 and 1914.5 The number of German-language citations declined more slowly than they might have, in part because of the refugee physicians who were publishing beginning in the 1930s and of course citing the literature with which they were familiar.6 But American citations of German-language medical literature did decline remarkably during and after World War I. It is in this context—the important but then sharply decreasing influence of German medicine—that it is easier to understand the changing role of Jelliffe as a conduit for German-language psychiatric and neuropsychiatric ideas.7 Jelliffe is particularly interesting because he was so conventional. In the first decades of the twentieth century, he took on himself the mission of educating other physicians about the newest developments, and he began by thinking that Germany and France had the most to teach him and his colleagues. He was active in many professional organizations, but above all he was a medical journalist, best known as the owner and managing editor of a leading medical journal, the Journal of Nervous and Mental Disease, from 1902 to 1944.8 As a journalist, Jelliffe was often undiscriminating in the material that he presented, assuming that any contribution was valuable and that he and his colleagues would in their practices make use of anything that was useful. In this way he played into the eclecticism that marked the American style in medicine for at least two centuries. He ranged widely, but he did know the difference between inferior and superior research. When working with Theodor Ziehen and Robert Gaupp in 1908, for example, he compared them to Emil Kraepelin; and he did not hesitate to pass judgment on the work of both leading and minor figures in medicine, including such criteria as the thoroughness of their history-taking or their laboratory investigations.9 Jelliffe was, however, slow to commit himself for or against any publication. At least in print, he tended to emphasize positive contributions, believing that almost any good work provided some helpful knowledge.10 Jelliffe’s personal intellectual evolution exemplified that of the American nervous and mental disease community. In 1890–91, he was undecided on a specialty but made the classic European tour—his Wanderjahr, as he liked to call it. He was more taken with France than with the rest of the Continent. Although he spent major blocks of time in Berlin and Vienna, it turned out that his German at first was not as functional as his French, and when his regular European travels began in 1902, he still favored the Latin countries. As late as his 1928 trip, he reported being in Paris, London, Antwerp, and Amsterdam—but not in Germany. Nevertheless, as he traveled more, he did put in a substantial amount of time in Germany, and he recognized both implicitly and explicitly the excellence of German nervous and mental disease specialists. In 1906 and 1907, when he was turning

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his attention to nervous and mental diseases and had spent almost two years studying in Europe, he devoted very long periods of time to study with Kraepelin in Munich. In 1908–9 he also spent a substantial time in Berlin, as well as in Berne with Paul Dubois, and in Paris with Joseph J. Déjérine. Jelliffe’s work, along with the work of his wife, Helena Jelliffe, and of William Alanson White in bringing out a translation of Dubois’s book The Psychic Treatment of Nervous Disorders a year after its publication in 1904, made him, beyond his work as a medical journalist, immediately a major figure in bringing neuropsychiatric writings to America.11 Before World War I, Jelliffe was becoming more and more deeply committed to psychoanalysis, and while his writing was not accepted as “orthodox” until the mid-1920s, he worked hard to bring the whole range of psychoanalytic literature, particularly the literature published in German, before his American colleagues. With W. A. White, Jelliffe in 1913 founded the first English-language psychoanalytic periodical, The Psychoanalytic Review, which from the beginning carried many translations from the German. Although he supported himself largely through his private medical practice, Jelliffe continued to travel a great deal in Europe, averaging one lengthy excursion abroad every other year from 1902 to 1930, except for the war years. Even when he missed meeting particular physicians and scientists notable for their publications, he often exchanged photos with the famous in a quaint, essentially nineteenth-century manner.12 Jelliffe made himself master of the European neurological and psychiatric literature through three standard means of biomedical communication: books he requested for review, reprints of articles he requested of authors, and journal exchange. Journal exchange was the means by which Jelliffe, by sending out subscriptions to his journal, received in exchange from the editors of other journals subscriptions to their publications. It meant that for very little money Jelliffe accumulated a stunning library of the world literature of medicine, particularly the specialty journals dealing with nervous and mental diseases. As late as 1937, he wrote flatteringly to the editor that “the Psychiatrisch-Neurologische Wochenschrift greets me weekly and I enjoy greatly seeing it.”13 And as editor, Jelliffe published abstracts of the articles that appeared in those journals, so that readers could, if they wanted, gain from Jelliffe’s publications a remarkable awareness of recent publications in Europe as well as the more accessible provincial American journals and society proceedings. As an editor, Jelliffe provided one more educational service to American physicians: He had a legendary memory, and when he accepted articles for publication in his own journals, he would ask authors to refer to relevant articles that had appeared in Europe.14 Thus for a generation, Jelliffe was an important counterforce to the constant tendency (found in all

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language groups) to cite publications exclusively from one’s own national medical community.15 Jelliffe’s editorial activities took him into another realm as well: translation. He encouraged many translations—almost all from German and French sources. Some he published in his journals. Many very important translations appeared in the Nervous and Mental Disease Monographs series that Jelliffe edited in collaboration with White beginning in 1908. This series immediately presented many translations from the German, including not only works of Jung and Freud but also translations that Jelliffe himself, or in collaboration with others, made of works on paranoia and on the application of the Wassermann serodiagnosis to psychiatry. Eventually, before 1940, the series included works by dozens of German authors.16 Unlike many American physicians, Jelliffe was able to read and to some extent speak at least French and German. In her journal from their trip to Europe in 1902, Jelliffe’s wife noted that on the ship crossing the Atlantic, “Ely has labored with a little Dutch, producing a series of swine-like grunts which a Dutchman who is instructing him pronounces very satisfactory.” Later on during that trip she reported that at a society banquet, “There were ten languages spoken at his table, all of which he insists he understood.”17 These candid observations reinforce the impression that Jelliffe’s approach to material in other languages was to extract the main ideas from the publications rather than to do refined textual analysis. It was no doubt this proclivity to generalize that led the fussy English psychoanalyst Ernest Jones in 1912 to say that “the trouble with all his work . . . [is] stupidity. He never seems to have the intelligence to grasp things, or to value them properly.”18 But Jelliffe was aiming at a different discourse than were a number of specialists in the early twentieth century—he shared with them a bourgeois outlook and veneration for canonical figures and the ideal of civilization, but he wanted to escape the underlying, and possibly restrictive, commitments concerning the nature of mental disease entities that, for example, Volker Roelcke has found in German psychiatrists of the late nineteenth and early twentieth centuries.19 In the course of acting as a transmitter of ideas and editing translations, of course Jelliffe encountered the usual problems that occur when people with different cultural backgrounds try to work together. Endless miscommunications, particularly concerning financial matters, appear in Jelliffe’s correspondence with Europeans who, in Jelliffe’s eyes, had wildly unrealistic ideas about rich Americans. At one point, for example, when one unhappy German author involved the German diplomatic service in their dispute, Jelliffe had to write: “We did receive an article from Dr. Grunewald which so far as our records can show was never asked for. We requested an abstract of an article of his but we did not request an Original Article. He sent us an Original Article, which as you state you translated, and then put an arbitrary price on it which

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we refused to pay as we have no need for it and it still lies in our safe. We have never published it nor do we intend to do so under the circumstances.”20 In many similar ways, Jelliffe ran into cultural differences that made his role as cultural transmitter difficult. Among the psychoanalysts, Jelliffe and White were for years very friendly with Wilhelm Stekel, who had become anathema to those close to Freud. When Stekel visited the United States, Jelliffe and White found him very agreeable personally, and Jelliffe turned to Stekel in 1924, for example, for assistance in obtaining copies of Paul Schilder’s works. But Jelliffe alienated Freud for some time just by being observed speaking to Stekel at meetings in Europe in 1921.21 Like many Americans, Jelliffe found German ideas of loyalty and orthodoxy difficult to work with. Despite his cosmopolitanism, he did not seem to understand Central European ideas of correct behavior. Jelliffe, for example, noted after the 1927 psychoanalytic congress that “intolerance and political ruses [handwriting unclear here] seem to differ in no essential degree among those who ‘know’ their motives, than among those ignorant of them. The chief difference, if any, seems to be the greater boorishness of the ‘knowers.’ Possibly it is bourgeois to be courteous; at least it takes up less time and seems to get somewhere.”22 One convenient and important index of Jelliffe’s efforts to make his American colleagues aware of the entire world of medical research was the abstracts section of the Journal of Nervous and Mental Disease. When he first became managing editor of that journal in 1902, he spelled out for his readers his aspirations: “Special attention is called to our Periscope [abstract] department in its altered form. Here the entire field of nervous and mental diseases will be covered monthly, and our subscribers will be furnished with a résumé of what is being done in this branch of medical science the world over.”23 A sample of the abstracts at five-year intervals from 1902 to 1937 (figure 5.3) provides a striking parallel to the citation data from general medical journals. Like all samples, this one has biases—not least that, over time, Jelliffe did an increasing proportion of the abstracting himself, primarily so he would not have to pay someone else to do the work. The divisions in the chart are by language, and so the German heading would include Austrian and Swiss entries—and the Swiss constituted an especially significant component of the German-language entries after World War I. The French heading could of course also include a significant number of Swiss or Belgian entries. The English heading is a particularly mongrel entry, for lumping publications from all over the British Empire with those from the United States hides the increasing provinciality and self-sustaining nature of the American medical community. In the field of psychiatry, the growing contempt of leading American practitioners for English psychiatry, which appeared to them very conservative, makes the idea of an Anglo-American community difficult to sustain in functional terms.24

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Figure 5.3. In sample years of the Journal of Nervous and Mental Disease, the percentage of abstracts of articles from the medical literatures published in different languages, 1902–37.

With all of these cautions, the figures still suggest some very interesting trends. The German presence in neuropsychiatry was still growing at the beginning of the century, persisting remarkably even in 1917 and to a lesser extent briefly after World War I before going into a dramatic decline. The big losers from the impact of World War I, however, were the French.25 But what is most striking, of course, is the overwhelming trend of Americans, even those as cosmopolitan as Jelliffe, to turn, over the course of several decades, to the now self-sufficient American medical community.26 Because Jelliffe was so typical, results similar to those displayed in figure 5.3 can be shown for other, parallel journals.27 A briefer sample of publications in the American Journal of Insanity, later renamed the American Journal of Psychiatry (figure 5.4) shows strikingly similar trends. Indeed, in this case the 1937–38 German citations were largely from one single area of practical therapeutics, the introduction of insulin shock therapy. While Jelliffe acted as an important importer of German nervous and mental disease research, no good data exist about the extent to which Americans learned from him and others who kept up with the German-language literature. One very obvious factor, however, was the way in which medical research and publication was thriving in the United States—to the point that by the 1910s and 1920s expertise was present to a significant extent on

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Figure 5.4. Long-term trends apparent in the proportions of citations of French and German medical publications in sample years of the American Journal of Insanity/American Journal of Psychiatry, 1902–38.

the western side of the Atlantic Ocean. Provincialism did not start operating in an extreme form until there was a practical, material basis for it.28 All of this is somewhat obvious or confirms impressionistic evidence. What is of special interest is what was imported from Germany to the United States—again using Jelliffe as a gauge. Several factors were operating. Jelliffe, especially after World War I, was under pressure to have more neurology content in the Journal of Nervous and Mental Disease. He himself converted substantially to psychoanalysis around 1910, and a significant proportion of the German-language abstracts were out of the psychoanalytic literature, which was substantially Austrian and Swiss rather than German. But at the same time, Jelliffe had studied with Kraepelin and maintained a good relationship with him (they were, for example, both avid botanists). Kraepelin even published twice in the Journal of Nervous and Mental Disease in the 1920s. Jelliffe therefore had a personal interest in that mainstream of German psychiatry. Moreover, he attempted to pay attention to all prominent and promising investigators and clinicians in Germany as elsewhere. In 1936, for example, in attempting to develop a correspondence with Ernst Stahl in Munich,

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Jelliffe wrote: “Should you wish to know more of me let me say I was a pupil of Prof. Kraepelin and of Friedrich Müller, a friend of Prof. Bumke of the Psychiatrische Klinik, of Profs. Rüdin and Schneider and Plaut at the Kaiser Wilhelm Institut für Psychiatrie.”29 Under these various circumstances, the abstracts from Germany in Jelliffe’s journal tended to be, in the first place, the anatomically oriented research of figures such as K. Brodmann as well as other investigations of the nervous system (and, in the 1920s, the endocrines). But in the second place, a significant proportion of the German-language publications noticed even before World War I consisted of psychoanalytic and other dynamic psychiatric materials. It takes only a brief glance at the specialty literature to see that Americans after World War I were interested in reductionistic physiological and chemical approaches to mental disorders, on the one hand, and in dynamic and psychotherapeutic approaches, on the other hand. Of course specific therapeutic innovations such as malaria fever therapy were also always of great interest and, as in the American Journal of Psychiatry noted above, in 1937–38 in all American psychiatric journals the bulk of the German-language material cited dealt with shock therapies. Jelliffe, then, represented the tendencies in the specialty areas in the United States and, insofar as he was effective, he brought German influence to reinforce those tendencies in the United States. He also, of course, still hoped to broaden the knowledge and outlook of his colleagues. Before World War I, despite the great prosperity and productivity of American physiologists, the anatomical approach within which Jelliffe matured continued to attract major interest, and it was natural to look to Europe, and particularly to Germany, for intellectual and scientific leadership. But after World War I, increasingly the competitive success of Americans in physiology changed the context of psychiatry and neurology.30 After World War I, neurosurgeons dominated the specialty of neurology in the United States, and under the leadership of Harvey Cushing and Walter Dandy and others, Americans, who were also leading the way, particularly in neurophysiology, increasingly were busy learning from each other rather than from any number of overseas investigators and surgeons. Indeed, insofar as Germans flourished in neuropsychiatry, they did so often on the basis of American money, the distribution of which was determined substantially by American biases.31 In psychiatry, Americans writing in the journals were interested in hospital management (about which they believed they had little to learn from abroad), in physiological investigations (on the assumption that the major psychoses must be based in biochemistry of some kind), and in dynamic psychiatry.32 The German medical literature increasingly was engaged in a different kind of discourse, emphasizing inheritance and factual, even epidemiological, aggregations and typologies that did not have the same

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physiological and psychological emphases as those appearing in American publications.33 And it is easy to understand why the French literature appeared to Americans to consist of irrelevant hairsplitting. The prominence of World War I in this discussion brings up a special aspect of the history of medicine that Jelliffe illustrates particularly well. It is that development noted above that has received very little notice from historians of medicine. I refer to the destruction of the research infrastructure in Europe to the extent that during and after that war, Americans were inadvertently forced to turn to one another for medical authority because the usual sources of knowledge and tradition in Europe became much less available. Jelliffe is particularly interesting because his correspondence gives concrete evidence of the impact of World War I on the research infrastructure in Europe. In addition, from 21 May to 21 October 1921, Jelliffe was in Europe on the first of his postwar tours. He visited France, northern Italy, Bad Gastein, Vienna, Amsterdam, Brussels, London, Munich (Kraepelin was unfortunately away), Berlin, Hamburg, and Braunschweig, where he attended the meetings of the Gesellschaft Deutscher Nervenärzte. What he found, as appears here and there in his correspondence, was demoralized research communities, mostly without the resources to resume cutting-edge investigations.34 He wrote to one correspondent in 1930, “As you may not know Vienna was my ‘Wanderjahr’ city in 1891 and its people and locale have always appealed to me strongly. It was sad to visit it after the war when compared to previous visits.”35 Jelliffe could not have been surprised. As late as 1920, Otto Marburg had written to Jelliffe: “In consequence of the bad state of our financial affairs it is not possible to purchase the papers [journals] published in Amerika. What we further require are apparatus and instruments, which have become worn with use.” Hans Haenel of Dresden wrote to Jelliffe early in 1921, trying to reestablish contact that had been disrupted and reminding Jelliffe of a case they had worked on together in 1909. Haenel wrote about the bad conditions, even hunger, and Jelliffe sent fifty dollars to the American Relief Administration so that food could be delivered to Haenel.36 But even after the passage of considerable time, evidence kept surfacing that Germans were aware that they were operating under a handicap. In 1928, Felix Stern wrote that he could not check a reference that Jelliffe, writing from America, had given him because a standard German-language medical journal, the Schweizer Medizinische Wochenschrift, was not available to Stern in Kassel.37 In 1937, Martin Grotjahn, now a refugee established in Topeka, Kansas, wrote to Jelliffe: “I should explain to you why I did not mention your work. I am familiar with a great many of your papers, which I read when I could obtain them, something which was not always easy in Germany.” Grotjahn then mentioned one German-language article of Jelliffe’s

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that Grotjahn had abstracted for the Zeitschrift für Neurologie und Psychiatrie in 1934. When writing in the United States in 1937, he continued, “I wanted to obtain additional information from the English literature, but I became frightened, confused, and discouraged by the abundance of material available. You have no idea how deeply the American journals have impressed me after having lived for four years in Nazi Germany without English literature, and after having been at the University of Berlin, which is supposed to be the German center of research, but which has been little short of sterile in the last few years.”38 Altogether, the tone of Jelliffe’s correspondents changed rather suddenly after World War I. The Germans wrote less patronizingly than in the past. Instead, they reminded Jelliffe of past ties and attempted to reestablish old relationships. Or they tried to use Jelliffe to promote their work in the United States and in the English-speaking world more generally. Or they wrote to muster support for awards of American money.39 And this change of course intensified in the 1930s, when the Nazi terror began and victims and their colleagues started pleading with Jelliffe to help them get out of Germany and secure a position in the United States.40 But even in earlier, more normal times after World War I, German biomedical workers had difficulty in reestablishing even a part of their earlier relationships. When Robert Gaupp wrote to Jelliffe in 1922 attempting to reestablish relations, Gaupp noted that their old friends were mostly now dead and that Kraepelin had retired.41 As late as 1924–25, Jelliffe was still trying to resuscitate his journal exchange arrangement with the Allgemeine Zeitschrift für Psychiatrie, for he had seen only scattered numbers since 1914. Jelliffe wrote to the current editor, “I had always had the pleasantest relations with Dr. Laehr and I saw no reason why it should not continue with you. I have many friends among the German psychiaters and would like to notice the Allg. Zeit. in the Journal regularly.”42 The old patronizing relationship of German physicians with their American colleagues would never be reestablished. Instead, the balance had begun to tilt toward the United States. Germans now wrote about their trips to America, and Jelliffe often hosted dignitaries who were visiting the New World for scientific purposes or were even looking for positions.43 And while Germans began to take more interest in visiting the United States, Jelliffe by the end of the 1920s was less interested in visiting Germany than he had been.44 Moreover, German medical professionals were becoming more interested in publishing in the United States. William Malamud wrote to Jelliffe from Heidelberg that Viktor von Weizsäcker was asking him “just how one could improve the exchange of views and cooperation between the men here and those on the other side [of the Atlantic]. I told him about your position that we send some of our work for publication in the Journal. He thought that

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would be very nice and suggested that we ask you too for contributions for his journal.”45 The visits of German physicians were to some extent welcomed by Americans. In 1929, Jelliffe wrote to August Bostroem of Munich: “We have been much stimulated by the visit of Prof. Spielmeyer, and also are looking forward to having Dr. Kahn with us. . . . Kindly give my best wishes to Prof. Bumke and if you meet Dr. Plaut or Dr. Rüdin, also my greetings to them.” But also in the late 1920s, Jelliffe wrote to an English colleague: “A surplus of psychoanalysts is among us lusting after the American dollar. How they all hate us because we have it and ‘give it to them.’ Ferenczi came first, then Rank and now Adler. It is all very amusing.”46 One accidental consequence of the war devastation was that, at least in Jelliffe’s experience, relationships with psychoanalysts recovered much more quickly than did those with other types of neuropsychiatric specialists in German-speaking countries. Although Jelliffe maintained his interest in neurology and neurophysiologically based psychiatry, his new friends in psychoanalysis were easily reestablishing ties with Americans. Moreover, since the analysts were not dependent upon physical facilities, their investigations tended to be fresh and interesting. It is no wonder that dynamic psychiatry from Austria, Germany, and Switzerland flourished in the United States after World War I and developed momentum that was intensified by the arrival of the refugees in the 1930s.47 And of course the presence of the refugees soon made the United States dominant in that area of psychiatry and, to some extent, other areas as well. I do not mean to exaggerate the extent to which German specialists recognized American medicine. Samples of citations in the Allgemeine Zeitschrift für Psychiatrie show that in the 1924–25 volume, the authors of articles turned exclusively to German-language serials and books—with the exception of one article in which the author recounted his visit to America.48 Volumes covering 1929 include only two citations to English-language publications (Cotton’s focal infection theory) and six French-language publications—all in the same extensive list of references of one author. All of the rest of the literature cited was from German-language sources, with one further exception: a summary of recent French ideas about schizophrenia, in which more French literature was cited.49 In one other sample from the same journal, a survey of the literature on psychiatry for the year 1923, in which 1,442 items were noticed, only 5 percent were from French-language publications and 6 percent from English-language publications.50 Such concrete evidence suggests that the bulk of German psychiatrists continued to operate into the 1930s without confronting the English-language literature seriously and extensively.51 Like Grotjahn, whom I quoted above, the Germans may have been vaguely aware of the literature coming out of North America, but they largely isolated any work from across the Atlantic. The samples from the

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journals suggest that German neuropsychiatric workers tended to segregate English-language publications rather than to integrate them routinely into the literature. This provincialism of the German specialists may have been even more extreme than that of their American colleagues—or it may have been realistic, for they were, as I have suggested, pursuing avenues of inquiry into mental diseases, such as inheritance and body types, that were different from those prominent in the United States, and Americans were not offering concrete therapeutic innovations that might have caught their attention, as sleep and shock treatments eventually did on both sides of the Atlantic.52 In 1927, Grete Frankenstein, a Berlin specialist, expressed one constant approach of dealing with American psychiatry: “Wenn auch das Geburtsland der wissenschaftlichen Psychiatrie Deutschland ist, so muss doch anerkannt werden, dass kein anderes Land diese Wissenschaft so systematisch verwertet hat wie die Vereinigen Staaten von Amerika, und zwar im Aufbau ihrer sozialen Fürsorge.”53 Nor can one be sure that the effect one sees in literature references is not simply the growth of national intellectual isolationism everywhere after World War I, not just in the United States. In 1903, authors of articles in the Allgemeine Zeitschrift für Psychiatrie had indeed cited, as one might expect, an overwhelming proportion of German-language references. But in that volume, there were three times as many French- as English-language references, although neither in such numbers (fifteen, as against five) as to have any significance. In the review of the world literature on psychiatry in 1902 in that same volume, the proportions were somewhat different: German 60 percent, French 13 percent, English 24 percent, Other 4 percent—not so very different from the American figures from the Journal of Nervous and Mental Disease in that less provincial period before World War I (in contrast to the 1920s and after).54 My aim in this paper has been primarily to raise questions. What, precisely, beyond neuroanatomy, therapeutic innovations, and psychoanalysis, was selected for transmission from Germany to the American medical community? What was not selected? And how did the interwar years prepare German physicians for the decades of American domination that followed World War II?55 Indeed, how much of that domination was based on the work of physicians who had left Germany and were employed in the United States and England by the 1930s—and, at least in the United States, in an environment perhaps unduly respectful of the émigrés?56 Examining the work of Smith Ely Jelliffe provides an opening for extending our understanding of the changing relationship between German and American psychiatry and neuropsychiatry. Jelliffe represented, as far as he could, the great tradition of medicine operating as a universal enterprise. In the 1920s, after World War I, he and many other Americans tried to reestablish old patterns of deference to prestigious German figures and institutions

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in psychiatry.57 But internationalism, much less the overwhelmingly derivative status of American psychiatry, faded away during and after the devastation of the 1914–18 war years—the accidental factor that historians of the biomedical sciences have yet to recognize adequately.58 There may be other dimensions within which to understand these international relations of medical communities. One is the purely quantitative dimension. Throughout the twentieth century, biomedical scientists and clinicians complained of having to master too much, and they used this “explosion of knowledge” to rationalize limiting their perspective to what they had time to read. Still another dimension may be the nature of psychiatric knowledge at any given time. Psychiatric knowledge was fundamentally clinical, and it was clinical experience that translated least well internationally, compared to specific laboratory tests or therapeutic techniques.59 Anyone could understand a Wasserman test or shock treatment, and both of them showed up well in various provincial neuropsychiatric literatures, regardless of the nation of origin. But both German and American psychiatrists were much less willing than Jelliffe, at least in the decades before 1940, to make the effort to extend their views of clinical impressions, such as somatic types or psychotherapies, beyond their immediate cultural communities in medicine.60

Notes 1. Transnational history is explored in Christopher A. Bayly et al., “AHR Conversation: On Transnational History,” American Historical Review 111 (2006): 1441–64. 2. Biographical background and context for this paper are drawn especially from John C. Burnham, Jelliffe: American Psychoanalyst and Physician, and His Correspondence with Sigmund Freud and C. G. Jung, ed. William McGuire (Chicago: University of Chicago Press, 1983), as well as the papers of Smith Ely Jelliffe (hereafter Jelliffe Papers), now deposited in the Library of Congress, Washington DC. Some citations to the Jelliffe Papers are based on their undefined provenance prior to their being deposited in the Library of Congress and so are cited without location. This paper focuses specifically on Jelliffe as an agent and reflector of German publication and practice; therefore many biographical details are omitted. 3. Samuel Zachary Orgel, Psychiatry Today and Tomorrow (New York: International Universities Press, 1946), 33. 4. See, for example, John Harley Warner, Against the Spirit of System: The French Impulse in Nineteenth-Century American Medicine (Princeton: Princeton University Press, 1998). 5. The figures are from Thomas Neville Bonner, American Doctors and German Universities: A Chapter in International Intellectual Relations, 1870–1914 (Lincoln: University of Nebraska Press, 1963). 6. The figures and a full discussion of general medical journals appear in John Burnham, “The Transit of Medical Ideas: Changes in Citation of European Publications

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in USA Biomedical Journals,” in Actas del XXXIII Congreso Internacional de Historia de la Medicina, ed. Juan L. Carrillo and Guillermo Olagüe de Ros (Sevilla: Sociedad Española de Historia de la Medicina, 1994), 101–12. In Smith Ely Jelliffe to G. T. W. H. Fleming, 22 November 1939 (Jelliffe Papers), Jelliffe observed to this Englishman that “Our ablest neurologists and psychiatrists are usually equipped with German— nearly all the Jews are and these make a large quota.” 7. A fascinating comparison can be made with a series of reports on material in Psychological Index/Psychological Abstracts by Samuel W. Fernberger: “On the Number of Articles of Psychological Interest Published in the Different Languages,” American Journal of Psychology 28 (1917): 141–50; “On the Number of Articles of Psychological Interest Published in the Different Languages (1916–1925),” AJP 37 (1926): 578–81; “On the Number of Articles of Psychological Interest Published in the Different Languages: 1926–1935,” AJP 48 (1936): 680–84; “On the Number of Articles of Psychological Interest Published in the Different Languages: 1936–1945,” AJP 59 (1946): 284–90. Fernberger’s findings are of special interest for two reasons: a substantial number of neuropsychiatric articles were included, and the parallels to my findings on medical publications and citations are remarkable. The number of German-language publications reached a peak in the period 1905–15, but under the impact of World War I they declined drastically and recovered only briefly around 1930, after which economics and politics caused a drastic, permanent decline. The number of French-language publications was about equal to the number of English and German publications except for those few years of increase in German publications; after World War I, however, French-language publications became relatively insignificant in number. 8. Some additional detail concerning Jelliffe’s editing appears in John C. Burnham, “The Founding of the Archives of Neurology and Psychiatry; Or, What Was Wrong with the Journal of Nervous and Mental Disease?” Journal of the History of Medicine and Allied Sciences 36 (1981): 310–24. 9. Smith Ely Jelliffe to P. Bailey, 18 November 1908, Jelliffe Papers; also quoted in Burnham, Jelliffe, 51–52. 10. For another evaluation of Jelliffe’s role as a transmitter of knowledge see James B. Mackie, “The Journal of Nervous and Mental Disease: The First 100 Years. III. 1902–1944. The 42–Year Editorship of Smith Ely Jelliffe, a Practical Mystic,” Journal of Nervous and Mental Disease 159 (1974): 305–18. 11. Smith Ely Jelliffe, “Glimpses of a Freudian Odyssey,” Psychoanalytic Quarterly 2 (1933): 318–29, contains an often amusing account of his travels and struggles with languages. 12. The Jelliffe Papers contain a substantial amount of correspondence that is the basis for the generalizations I make. 13. Smith Ely Jelliffe to Joh. Bresler, 12 April 1937, Box 3, Jelliffe Papers. 14. Before 1917, Jelliffe was not the primary editor for articles in the Journal of Nervous and Mental Disease, and the extent to which he made suggestions in his role as managing editor is unknown, although he was also editing other journals in those years. There is in the Jelliffe Papers plenty of evidence of his editing influence after 1917. 15. Or Jelliffe’s role could be indirect; in 1928 he commented to a Boston colleague: “I think it is a pity that Murray and the others had not read the Hollos &

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Ferenczi work on the psychological symptoms of general paresis.” Smith Ely Jelliffe to E. W. Taylor, 7 February 1928, Jelliffe Papers. Jelliffe obviously expected Taylor to raise the consciousness of his colleagues in Boston. 16. Mackie, “The Journal of Nervous and Mental Disease,” 307–9, takes up Jelliffe’s work as translator and also mentions his important role as a textbook author. In the several editions of the main Jelliffe and White textbook, there are no accessible indicators of the amount of German work the two authors were transmitting in that textbook. 17. Helena Leeming Jelliffe Journal, 24 August 1902 and 7 September 1902; Jelliffe Papers. 18. Ernest Jones to A. A. Brill, 4 March 1912, Brill Papers, Library of Congress; courtesy of Hans Pols, to whom I am very grateful. 19. Volker Roelcke, “Biologizing Social Facts: An Early 20th Century Debate on Kraepelin’s Concepts of Culture, Neurasthenia, and Degeneration,” Culture, Medicine, and Psychiatry 21 (1997): 383–403; Volker Roelcke, Krankheit und Kulturkritik: Psychiatrische Gesellschaftdeutungen im bürgerlichen Zeitalter, 1790–1914 (Frankfurt: Campus, 1999), chap. 5. 20. Smith Ely Jelliffe to H. O. Sommer, 4 October 1923, Box 8, Jelliffe Papers. Smith Ely Jelliffe to Mary R. Barkes, 9 April 1928, Jelliffe Papers, noted that the psychoanalytic publishing house “the Int. Psa. Verlag have asked impossible prices for translation rights.” 21. See, for example, William Alanson White to Smith Ely Jelliffe, 16 June 1921, and Smith Ely Jelliffe to William [Wilhelm] Stekel, 1 February 1924, Jelliffe Papers. Sigmund Freud to Smith Ely Jelliffe, 11 April 1926, in Burnham and McGuire, Jelliffe, 224. 22. Jelliffe notebook, 107, Box 34, Jelliffe Papers. 23. “Announcement,” Journal of Nervous and Mental Disease 29 (1902): 64. 24. One gets the impression from samples of German citations and abstracts reported below that German psychiatric workers shared the Americans’ view that English psychiatry was not very interesting at all. Smith Ely Jelliffe, reporting in the Journal of Nervous and Mental Disease 56 (1922): 247, commented (probably with undue hope and optimism) that “only with the great war did English psychiatry awake from a formless static inertia that was difficult to understand, Stoddart among the older group alone comprehending the real situations as Maudsley had seen them. Mercier’s crabbed satire had seemed to cramp psychiatry in England almost as effectually as he himself had been locked up by his venom and his rigid ‘logic,’ both which he used to ridicule his adversaries.” 25. The decline of attention to French medical writings may have been not just accidental. Claude Debru and Jean Gayon, “Introduction,” in Les Sciences Biologiques et Médicales en France 1920–1950, ed. Claude Debru, Ajean Gayon, and Jean-Francois Picard (Paris: CRNS Editions, 1994), 9, speak of the years between 1920 and 1950 as characterized by stagnation and preparation for renewal in the biomedical sciences in France. As noted above, the decline in French-language publications in the field of psychology was, if anything, more dramatic. 26. There are many fine points in figure 5.3 that might be explored. Clearly the “Other” category, after World War I, was in part filling the vacuum created by a decline in German publications, for example. 27. One comparison, to be sure that the Journal of Nervous and Mental Disease proportions were not particularly idiosyncratic, was provided by the rival Archives of

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Neurology and Psychiatry. In 1938, for example, the Archives carried a large number of abstracts, the profile of which roughly corresponds to that of the 1937 figures for the Journal of Nervous and Mental Disease; the Archives carried only 16 percent from German-language publications, 13 percent from French, 62 percent from English, and 8 percent from Other. 28. British and German Historiography, 1750–1950: Traditions, Perceptions, and Transfers, ed. Benedikt Stuchtey and Peter Wende (Oxford: Oxford University Press, 2000), contains several examinations of the provincialism and insularity of German and English scholars that illustrate how a critical mass of expertise was able to sustain provinciality and insularity in another, but perhaps comparable, field. Or see, for an additional example, Stanley Coben, “The Scientific Establishment and the Transmission of Quantum Mechanics to the United States, 1919–32,” American Historical Review 76 (1971): 442–66. Fernberger, “On the Number of Articles,” 146, found that the English-language psychological articles of 1915 were already two-thirds of American origin. By 1939, this proportion had risen to 83 percent, which, given that 64.5 percent of all psychological journal publications were in English (and only 18.6 percent in German), meant that Americans dominated that whole literature, including much material of neuropsychiatric interest; see Samuel W. Fernberger, “A National Analysis of the Psychological Articles Published in 1939,” American Journal of Psychology 53 (1940): 295–97. 29. Smith Ely Jelliffe to Ernst K. Stahl, 21 January 1936, Box 18, Jelliffe Papers. 30. For example, omitted from the abstract sample was a “Collected Abstract,” Orthello R. Langworthy and Edward S. Taube, “The Control of the Pupillary Reaction by the Central Nervous System: A Review,” Journal of Nervous and Mental Disease 86 (1937), in which the authors cited thirty-three English-language publications but only ten in German (and but one in French!). 31. See, for example, Matthias M. Weber, “Psychiatric Research and Science Policy in Germany. The History of the Deutsche Forschunganstalt für Psychiatrie (German Institute for Psychiatric Research) in Munich from 1917 to 1945,” History of Psychiatry 11 (2000): 235–58; and the contribution by Eric J. Engstrom in this volume. Some of the complex context of American financing of German research appears in Robert E. Kohler, “A Policy for the Advancement of Science: The Rockefeller Foundation, 1924–29,” Minerva 16 (1978): 480–515. See, too, the report of Cornelius Borck, “Mediating Philanthropy in Changing Political Circumstances: The Rockefeller Foundation’s Funding for Brain Research in Germany, 1930–1950,” Rockefeller Archive Center Newsletter (Spring 2001): 3–5; and Rockefeller Philanthropy and Modern Biomedicine: International Initiatives from World War I to the Cold War, ed. William H. Schneider (Bloomington: Indiana University Press, 2002). 32. See, for example, the emphasis put on dynamic approaches by F. J. Wertheimer, “Kurzer Überblick über die amerikanische Psychiatrie der Jahre 1910–1920,” Allgemeine Zeitschrift für Psychiatrie 81 (1925): 442–51; of course Wertheimer was writing from Adolf Meyer’s clinic at Johns Hopkins. 33. See Volker Roelcke, “Naturgegebene Realität oder Konstrukt? Die Debatte über die ‘Natur’ der Schizophrenie, 1906 bis 1932,” Fundamenta Psychiatrica 14 (2000): 44–53; and the contribution by Volker Roelcke in this volume. In 1921, Jelliffe wrote to his intimate friend White that “practically little of the older Kraepelinian Psychiatry is of very much value. Still at the same time, I feel sure that a certain amount of linking

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of French and German ideas with our own may be advisable. They are reaching out for some more dynamic explanations even behind the descriptive mask.” Smith Ely Jelliffe to William Alanson White, 16 December 1921, Box 20, Jelliffe Papers. 34. Although historians have for the most part not noticed the devastating effects of the war upon biomedical and other sciences in Germany and France, contemporaries recorded observations similar to those of Jelliffe. Abraham Flexner, probably the most knowledgeable person of any nationality, wrote repeatedly into the 1920s of the damage that the war had done to research and learning in Europe; see Thomas N. Bonner, Iconoclast: Abraham Flexner and a Life in Learning (Baltimore: Johns Hopkins University Press, 2002). Another perspective is offered by Paul Weindling, “The Rockefeller Foundation and German Biomedical Sciences, 1920–40: From Educational Philanthropy to International Science Policy,” in Science, Politics and the Public Good, ed. Nicolaas A. Rupke (Basingstoke: Macmillan, 1988), 119–40, who suggests that the shift in scientific production from Germany to the United States may have begun before World War I, and how the Rockefeller Foundation, despite internal differences, for some years after the war attempted to save the German scientific infrastructure by funding younger, unsupported investigators. 35. Smith Ely Jelliffe to J. J. Michaels, 14 January 1930, Jelliffe Papers. 36. Otto Marburg to Smith Ely Jelliffe, 26 April 1920, Box 13, Jelliffe Papers. Hans Haenel to Smith Ely Jelliffe, 1 February 1921, Box 8, Jelliffe Papers. 37. Felix Stern to Smith Ely Jelliffe, 30 November 1928, Box 18, Jelliffe Papers. 38. Martin Grotjahn to Smith Ely Jelliffe, 27 August 1937, Box 8, Jelliffe Papers. This letter is also quoted in David Krasner, “Smith Ely Jelliffe and the Immigration of European Physicians to the United States in the 1930s,” Transactions and Studies of the College of Physicians of Philadelphia, Series 5, no. 12 (1990): 49–67. Other high-quality refugees made similar observations (as did my own postdoctoral teacher, David Rapaport). 39. See, for example, O. Bumke to Smith Ely Jelliffe, 30 November 1935, Box 3, Jelliffe Papers, asking for support for Bumke’s assistant, who was applying for Rockefeller money. 40. This subject is covered thoroughly in Paul Weindling’s chapter in this volume, and in Krasner, “Smith Ely Jelliffe and the Immigration of European Physicians,” so it is not taken up here. The change in tone was often very pitiful in the 1930s; see, for example, the Bien file in the Jelliffe Papers, Box 2. 41. Robert Gaupp to Smith Ely Jelliffe, 16 October 1922, Box 7, Jelliffe Papers. 42. Smith Ely Jelliffe to G. Ilberg, 8 October 1924 and 19 January 1925, Box 9, Jelliffe Papers. G. Ilberg to Smith Ely Jelliffe, 21 December 1925, ibid., noted, perhaps with understatement: “Die lange Kriegszeit und die schwere Zeit nach dem Krieg haben den Zusammenhang zwischen den ausländischen und den deutschen Fachgenossen gelockert” (The long wartime and the difficult time since the war have loosened the bond between foreign and German specialists). 43. See, for example, Gaupp to Jelliffe, 16 October 1922; F. Plaut to Smith Ely Jelliffe, 23 January 1925; Alfons Jakob to Smith Ely Jelliffe, 16 February 1924. 44. See, for example, Smith Ely Jelliffe to Hans Strauss, 23 August 1929, Box 18, Jelliffe Papers. Although the evidence is only vaguely impressionistic, correspondence by the 1930s probably was increasingly conducted in English, not German. 45. William Malamud to Smith Ely Jelliffe, 13 December 1925, Box 13, Jelliffe Papers. Or see the correspondence from Eugene J. Harnik to Smith Ely Jelliffe, 5

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October 1932, Box 8, Jelliffe Papers. Harnik wanted to publish in the United States, as he reluctantly began to see was advisable and as Jelliffe encouraged, but as Harnik observed, “The communication with such far distant countries and between foreign countries with other idioms is slow and difficult.” 46. Smith Ely Jelliffe to August Bostroem, 19 December 1929, Box 2, Jelliffe Papers. Smith Ely Jelliffe to S. A. K. Wilson, 11 January 1927, Box 22, Jelliffe Papers. Theodor Reik to Smith Ely Jelliffe, 3 November 1929, Jelliffe Papers, wrote that “I have always been an Anglomaniac. Now I feel it hard that none of the eleven books I have written are translated into English.” Smith Ely Jelliffe to William Alanson White, 7 April 1925, Jelliffe Papers, had already concluded that “We evidently have been successful in what we have tried to do without any advantages that they [the Europeans] have, and they with all the advantages have got to keep borrowing money and being supported by philanthropists; hence they apparently hate us.” 47. In 1915, all of the abstracts appearing in the Psychoanalytic Review were from German-language publications. By 1926, the proportion was German 39 percent, English 54 percent. After the arrival of large numbers of refugees in 1937, the proportions were German 43 percent, French 24 percent, and English 33 percent. The classic account of the German emigration is by Marie Jahoda, “The Migration of Psychoanalysis: Its Impact on American Psychology,” in The Intellectual Migration, ed. Donald Fleming and Bernard Bailyn (Cambridge, MA: Harvard University Press, 1968), 420–45. Nathan G. Hale, Jr., The Rise and Crisis of Psychoanalysis in the United States: Freud and the Americans, 1917–1985 (New York: Oxford University Press, 1995), especially chaps. 7 and 8; and Uwe Henrik Peters, Psychiatrie im Exil: Die Emigration der dynamischen Psychiatrie aus Deutschland 1933–1939 (Düsseldorf: Kupka Verlag, 1992). 48. Another 1925 volume (82) included no French and just one English source. The inevitable exception was a literature review of the problem of alcoholism, in which out of 135 references, the author cited seven from French-language sources and twelve from English-language sources. Obviously where only one or two authors in a volume cited non-German sources, the suggestion is that all of the others did not or did not want to read the English-language neuropsychiatric literature. 49. There were two citations from non-major-language sources. The article was Arthur Kronfeld, “Der Schizophrenie-Begriff in der franzöischen Psychiatrie der Gegenwart,” Allgemeine Zeitschrift für Psychiatrie 92 (1929–30): 173–91. 50. Otto Snell, ed., “Bericht über die Literatur im Jahre 1923,” Allgemeine Zeitschrift für Psychiatrie 81 (1925), supplement. One indicative subsection, Max Bräuner’s “Serologie,” 160–76, had ninety-six references to German-language items and none at all to either French or English items. 51. An extensive sample of sixteen hundred pages of the 1927 volumes of the Zeitschrift für die gesamte Neurologie und Psychiatrie, which was more heavily neurological, perhaps more akin to the Journal of Nervous and Mental Disease, shows that there were 103 references to French-language publications, 107 to English-language publications, and 101 to Others—including many Russian- and Dutch-language publications. This may seem like a substantial number of references from other national literatures, but it probably did not total over 5 to 10 percent of the references in the journal, if that much. The rest were in German. Many authors in this journal tended to cite one or two French and one or two English publications, almost as token references, incidental to their overwhelming dependence on German-language references. For example

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(and this is a typical example), H. Kufs, “Über die Bedeutung der optischen Komponente des amaurotischen Idiotie,” Zeitschrift für die gesamte Neurologie und Psychiatrie 109 (1927): 452–57, had seventy-one references, only two of which were not to the German literature: one was to Ramon y Cajal, writing in Spanish, and one to a paper in the British journal Brain. Inspection of the references in a larger sample from additional volumes that were not subjected to exact counting showed no change in general pattern. I have not investigated the biasing factor of post–World War I German nationalism that reinforced provincial limitations. 52. Of course provincialism and isolation from foreign sources was appropriate when the authors were dealing with national or local legal arrangements for the mentally ill. In such writings, the most that could be hoped for was comparative material; see, for example, [nfn] Waetzoldt [of Berlin], “Psychiatrische und psychohygienische Reiseeindrücke aus Nordamerika,” Zeitschrift für psychische Hygiene 2 (1929): 34–49. 53. Grete Frankenstein, “Psychiatrische Sozialarbeit in den Vereinigen Staaten von Amerika,” Zeitschrift für die Gesamte Neurologie und Psychiatrie 110 (1927): 325. “If Germany is the birthplace of scientific psychiatry, it must be acknowledged, however, that no other country has utilized this science so systematically as the United States of America, and, to be sure, in the formation of their welfare system.” 54. Once again the figures suggest that French-language psychiatric literature and, as noted above, French-language general medical literature, was being squeezed out in both American and German citations. 55. See for example Peter J. van Strien, “The American ‘Colonization’ of Northwest European Social Psychology after World War II,” Journal of the History of the Behavioral Sciences 33 (1997): 349–63. 56. Stephen T. Casper, “Atlantic Conjunctures in Anglo-American Neurology: Lewis H. Weed and Johns Hopkins Neurology, 1917–1942,” Bulletin of the History of Medicine 82 (2008): 646–71, explores the changing attitudes toward foreigners in a closely related U.S. context. 57. For some years, study in Germany persisted in giving a certain cachet to an American’s record—perhaps because of superior theoretical training in the natural sciences. See Coben, “The Scientific Establishment.” And some Americans, other than internationalists like Jelliffe, published in German journals just as Americans had in years past, albeit sometimes still in a segregated context; see, for example, A. Peterson Saunders, “Beschäftigungstherapie der Geisteskranken in Illinois,” Zeitschrift für die gesamte Neurologie und Psychiatrie 86 (1923): 222–26. 58. Modris Ekstein, “War, Memory, and the Modern: Pilgrimage and Tourism to the Western Front,” in World War I and the Cultures of Modernity, ed. Douglas P. Mackaman and Michael Mays (Jackson: University of Mississippi Press, 2000), 151– 60, describes the changing general historical memory of World War I—in which devastating destruction tended to drop out of the conceptualization of the war. 59. This pattern is explored in a very different context in John C. Burnham, “Biomedical Communication and the Reaction to the Queensland Childhood Lead Poisoning Cases Elsewhere in the World,” Medical History 43 (1999): 155–72. 60. It may be, for example, that a very rigorous, technical version of psychoanalysis was transferred more easily to the United States because of the nature of the knowledge as well as institutional factors.

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Chapter Six

“Beyond the Clinical Frontiers” The American Mental Hygiene Movement, 1910–1945 Hans Pols The term “mental hygiene” represents the public health perspective within psychiatry. Mental hygiene psychiatrists were guided by the ideal of prevention: they designed and promoted intervention strategies to treat mental illness in its incipient stages, to prevent mental disorder from arising or from becoming worse, and to promote mental health in the general population. The concepts of mental hygiene and mental health that were central in their endeavors were inherently flexible and inclusive, which made them appealing to a great number of constituencies, both within and outside of psychiatry. Throughout the period under consideration, these concepts changed considerably, although the concept of mental health continued to contain strong evaluative and normative components, and was therefore influenced by cultural and ideological components. Mental hygienists considered mental health as an essential condition to meet the demands of citizenship (and mental disorder as one of the main causes for social disorder). Because mental hygienists explicitly connected the mental health of individuals to national and, later, international concerns, mental hygiene activities appeared to be relevant to broader social and political goals. Mental hygienists aimed to contribute to building a modern society based on scientific insights into human nature. Because of their emphasis on the importance of treating mental illness in its incipient stages, mental hygienists increased the domain of psychiatry beyond the confines of the mental hospital and the treatment of severe and persistent forms of mental illness by including the treatment of a variety of less severe mental conditions in outpatient settings. They consequently brought an increasing range of behaviors, thoughts, and emotions within the purview of psychiatry. To address the large number of mental conditions needing attention, mental hygienists encouraged general practitioners, psy-

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chologists, social workers, teachers, and parents to become acquainted with the symptoms of mental disorder and of incipient forms of mental illness and mental distress, because they generally encountered them first. Apart from getting professionals and lay people involved in mental hygiene efforts and thereby greatly increasing the size of the mental hygiene workforce, a small number of mental hygienists were interested in developing structural prevention methods that would alter the social, cultural, political, and economic factors that influence the prevalence of mental illness and distress in modern society. They were concerned with the prevalence of mental illness and mental disorder, which they considered to be symptoms of structural social problems that could be rectified by social engineering. These mental hygienists were inspired by highly utopian motives; they were convinced that by changing structural conditions, the mental health of the nation would improve. In order to guide this process, they hoped to develop a science of human nature, which would incorporate psychiatry, psychology, sociology, anthropology, and other social sciences. Mental hygiene ideas were developed and propagated by a small group of psychiatrists who founded the National Committee of Mental Hygiene (NCMH) in 1909 in New York City.1 The aims of the NCMH were to improve conditions in mental hospitals, stimulate the establishment of outpatient clinics and research in psychiatry, improve the quality of psychiatric education in medical schools, develop measures to prevent mental illness, and engage in public health education. According to John Burnham, the initiatives and activities of the NCMH were more significant than those of the American Psychiatric Association in stimulating the growth of psychiatry as a science and as a profession before 1950.2 During its first decade of operation, the NCMH received generous funding from the Rockefeller Foundation, which was considering the establishment of a mental hygiene division itself. Instead, it chose to fund the activities of the National Committee before it formulated its own program in psychiatry in 1929. During the 1910s, the NCMH focused on improving mental hospital care and stimulating the establishment of outpatient clinics. During the 1920s, its programs focused on childhood and the establishment of child guidance clinics. During the Depression decade of the 1930s, it proposed a variety of community mental hygiene programs to safeguard the mental health of the population as a whole. The psychiatrists of the National Committee were aware of developments in European psychiatry and selectively included elements that were congenial to them in their programs. They were inspired by the psychiatric research conducted at German universities and by the development of outpatient care there. They also displayed a keen interest in the psychotherapeutic methods of Paul Dubois, Pierre Janet, Carl Gustav Jung, and Sigmund Freud. They aimed to stimulate the development of psychiatry on

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an international scale by organizing international conferences, by making fellowships available for advanced training, and by publicizing their initiatives. They specifically aimed to stimulate the development of extramural or outpatient psychiatric care worldwide. In 1922, the International Committee for Mental Hygiene was established to coordinate the activities of mental hygiene organizations worldwide and to stimulate the establishment of national committees (the British National Council for Mental Hygiene was founded in 1922 by Sir Maurice Craig; the German Society for Mental Hygiene (Deutscher Verband für Psychische Hygiene) was founded by Professor Robert Sommer in 1925).3 The psychiatrists who set up national committees for mental hygiene in their own countries were encouraged by the American examples and used them to foster the development of their discipline and mental health care in their own countries, blending the American example and indigenous approaches to mental hygiene.4

Adolf Meyer’s Psychiatry of Adjustment The dynamic psychiatry of Adolf Meyer, who has been called the most influential American psychiatrist of the first half of the twentieth century, provided the basic orientation and philosophy of the mental hygiene movement.5 According to Gerald Grob, Meyer’s importance was “due in part to the fact that he served as a conduit through which European psychiatric innovations came to the United States.”6 Before moving to the United States in 1892, Meyer had been a student of August Forel in Switzerland. During his first years in the United States, Meyer conducted research according to the neurological tradition then common in German psychiatry by correlating brain lesions found during dissection with symptom patterns that had been observed when patients were still alive. At the turn of the twentieth century, he came to emphasize the observation and explanation of the behavior of patients in a dynamic, holistic, and functionalist perspective that focused on the dynamic relationship between individual and environment.7 In a number of influential articles, Meyer illustrated his new perspective by explaining the development of schizophrenia as the outcome of inadequate ways of dealing with life’s challenges, which led to increasingly ineffective behavior resulting in withdrawal and reclusiveness. Ultimately, these patients had come to live in a dreamworld of wish and make-belief and were out of touch with reality and the people around them.8 In formulating his dynamic psychiatry, Meyer was influenced by the social Darwinism of Herbert Spencer and the functionalism of Charles Sanders Pierce, John Dewey, and William James. In his perspective, mental disorder was behavioral in nature and could be defined as a form of maladjustment or a state in which individuals were no longer able to respond adequately

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to the demands of their environment. Conversely, Meyer defined mental health as a state of adjustment, characterized by both an objective perspective on life and the ability to act decisively. Meyer defined adjustment in commonsense terms as the ability to meet social expectations and to adhere to middle-class social norms. As a consequence, his approach increased the domain of psychiatry beyond a concern with mental illness to include a wide range of behavior that could be characterized as not meeting social approval. Mental hygienists placed criminality, pauperism, alcoholism, prostitution, and vagrancy within the domain of psychiatry. Explaining these “aberrant” behaviors or conditions by reference to the psychopathology of individuals, mental hygienists discounted the role of social factors such as inequality and poverty. In addition, they presented a new and individualized approach that, if implemented systematically, would reduce social disorder and thereby increase social cohesion. Meyer’s dynamic psychiatry was inspired by Emil Kraepelin’s work.9 In 1896, Meyer had spent six weeks at Kraepelin’s Heidelberg clinic.10 Meyer greatly admired Kraepelin’s systematic way of observing the behavior of patients. He adopted Kraepelin’s system of classification and successfully introduced it as the basis for systematic recordkeeping in mental hospitals in the United States. Later, he became critical about Kraepelin’s somatic explanations for dementia praecox, which he felt were speculative.11 Meyer was also inspired by new psychotherapeutic approaches developed in Europe. He was a founding member of the American Psychoanalytic Association and selectively incorporated elements of psychoanalysis in his theories.12 He criticized Freud’s speculative theories on the nature of the unconsciousness and the role of sexuality in human development, but found his emphasis on the role of mental factors useful. Later in life, he pointed out the British influences on his own thinking, in particular the work of Thomas Huxley and John Hughlings Jackson.13

Psychiatry in the Community: Mental Hygiene in the 1910s When the National Committee of Mental Hygiene was founded in 1909, the status of psychiatry was at an all-time low. Psychiatrists worked in overcrowded mental hospitals that housed individuals with severe and persistent forms of mental illness who hardly responded to treatment; as a consequence, therapeutic pessimism abounded. In addition, there were few opportunities for research in mental hospitals. During the 1910s, mental hygienists argued that psychiatry should extend its domain beyond the confines of the mental hospital into the community by establishing outpatient clinics. At the same time, they were interested in eugenics, which provided a perspective for analyzing the presence of mental illness in the population as a whole. Through

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a number of psychiatric surveys, they aimed to ascertain the prevalence of mental illness, mental disorder, and maladjustment in the community. According to Meyer’s dynamic psychiatry, mental illness was the final stage of a process of habitual disorganization that started with innocuous and relatively innocent failures to deal with life’s challenges. On the basis of these ideas, mental hygienists argued that it would be much more effective to provide treatment for mental illness in its incipient stages, which would prevent the development of forms of severe and persistent mental illness. However, individuals at risk of becoming mentally ill were not found in mental hospitals but in the community and could best be reached by opening outpatient clinics in the major population centers. The example of the network of German outpatient clinics (Fürsorgestelle) organized by Gustav Kolb and Hans Roemer probably influenced his thinking.14 Meyer proposed the establishment of outpatient clinics for the treatment of individuals with mental disorders.15 Outpatient clinics also aided former patients in reestablishing themselves in society. These clinics were staffed with social workers who could educate the family and provide assistance in finding work. Mental hygienists also encouraged the establishment of psychopathic hospitals associated with the major medical schools. These clinics followed the German example as research institutions associated with university medical schools where extensive study could be made of a small number of interesting cases. They focused on the treatment of acute cases of mental illness and were established, at first, in Ann Arbor, Boston, and at Johns Hopkins University in Baltimore, where Meyer became the medical director in 1913.16 The establishment of outpatient clinics was one of the more practical elements of the program of the National Committee in the 1910s. A small number of mental hygienists also developed a broader perspective on American society by investigating the prevalence of mental illness outside mental hospitals. According to them, treating individuals suffering from mental disorder alleviated distress but did not reduce the prevalence of mental illness. Because they were convinced that there was a direct relationship between the health of the social body as a whole and the mental health of individuals, they argued that effective preventive interventions had to address structural and society-wide issues. As Thomas W. Salmon, the first medical director of the NCMH (1912–22), stated it: There has been formulated the exceedingly useful hypothesis that society, like the individual, has its diseases, that these “social diseases” have their pathology, their external manifestations or symptomatology, in some cases their epidemiology and their specific or general measures of prevention or of control.17

To identify and address the diseases of society, only measures addressing society as a whole would be effective. Salmon thought that developing

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psychiatric approaches to crime, the problems of childhood, immigration, and education were the most promising. The tenets of eugenics had already been formulated in Germany and the United Kingdom; eugenics had been taken up with great enthusiasm by a number of American physicians and social reformers.18 Eugenics provided a perspective in which the prevalence of mental illness in society as a whole could be investigated and it also provided suggestions for intervention. Henry H. Goddard, in his Kallikak Family (1912), ascribed a wide variety of behaviors that met with social disapproval, from criminality, alcoholism, prostitution, and vagrancy, to feeblemindedness or mental retardation, which, according to him, was to a large extent inherited.19 For a period of time, public health activists, physicians, and psychiatrists fostered a moral panic about the “menace of the feebleminded” and advocated institutionalization, special classes, and, at times, sterilization as solutions to counter this menace. Feeblemindedness became a psychiatric condition that attracted widespread public attention, mostly because it was perceived as a threat within the community. Soon, mental hygienists viewed feeblemindedness as one of many psychopathological conditions that could explain social maladjustment and that had to be managed assiduously to neutralize its effects on society as a whole. In a pioneering survey of Nassau County (located east of New York City) conducted in 1916, the psychiatrist Aaron Rosanoff aimed to investigate the psychiatric causes of social maladjustment. This survey was conducted by the Eugenics Record Office at Cold Spring Harbor (Nassau County) and funded by a grant of the Rockefeller Foundation to the NCMH. Rosanoff investigated all individuals whose maladjustment had been so pronounced that they had come to the attention of public authorities (the courts, philanthropic agencies, or the police). He concluded that most of these individuals suffered from mental disorders, in particular psychopathy.20 Rosanoff also demonstrated that various forms of maladjustment were present in members of the same family, suggesting a hereditary component. Mental hygienists further undertook surveys of prison populations and came up with similar conclusions. In particular, recidivists were diagnosed with a number of psychopathological conditions.21 These surveys demonstrated that psychopathology could be found outside mental hospitals and was responsible for crime and lawbreaking. They also demonstrated that the social and economic cost of mental disorder was exceedingly high. Mental hygienists indicated possible intervention strategies ranging from institutional segregation and sterilization to public health education campaigns informing the public about the hereditary nature of mental illness. Their attention was focused on “outsiders”: immigrants, working-class individuals, the feebleminded, individuals with mental disorders, criminals, and others living on the fringes of civil society. Mental hygienists aimed to promote social cohesion by addressing

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the mental disorders of these individuals, which would either rehabilitate or neutralize them by institutional segregation. Eugenics held the attention of American mental hygienists for only a relatively short period during the 1910s.22 As Wendy Kline has suggested in her study on the history of eugenics, pronatalist concerns with the stability, fertility, and psychological well-being of middle-class families common in the 1920s were advocated by the same individuals who had supported eugenics and, during the previous decade, the segregation and sterilization of socially undesirable individuals.23 During the 1920s, most mental hygiene activities addressed middle-class families and focused on childrearing. American mental hygienists rarely commented upon the eugenic ideas promoted by psychiatrists in Nazi Germany, although they were troubled by the prominent role played by Ernst Rüdin at the second International Congress on Mental Hygiene held in Paris in 1937. Unfortunately, they had no influence on the program for that meeting, although they were able to prevent Rüdin from being elected to the vice presidency of the International Committee for Mental Hygiene.24 Rüdin was the dominant figure in German psychiatry at that time. He was able to transform the Deutscher Verband für Psychische Hygiene from an organization interested in a variety of goals, among them improving mental health care facilities, occupational therapy, and education, as well as establishing outpatient clinics, into one almost exclusively interested in eugenics.25

World War I and Military Psychiatry Soon after the outbreak of the Great War in 1914, the attention of psychiatrists worldwide was captured by a phenomenon with which they had thus far been unfamiliar: shell shock. A number of British psychiatrists and neurologists, of whom W. H. R. Rivers became the best known, came to view it as a psychological reaction to the experiences of warfare and developed treatment methods to alleviate its symptoms.26 Because the United States entered the war only in April 1917, American psychiatrists had ample time to prepare. The National Committee collected and analyzed publications on military psychiatry that appeared in the international medical literature.27 In March 1917, the U.S. Surgeon General sent Salmon and two colleagues to inspect American army camps at the Mexican border; they concluded that mental disorders there were three times as prevalent as compared to civilian life.28 In May, Salmon traveled to the United Kingdom to survey the psychiatric management of shell shock in the British armed forces. His comprehensive report formulated psychiatric policies relating to selection and treatment; it became the basis for military psychiatry in the American Expeditionary Forces and has been called a classic in the annals of military psychiatry.29 In his report, Salmon formulated the principles of military psychiatry

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that were later summarized with the acronym PIES (Proximity, Immediacy, Expectancy, and Simplicity).30 In his report, Salmon advised the U.S. armed forces to screen recruits and exclude “insane, feeble-minded, psychopathic, and neuropathic individuals.”31 The greater part of his report was devoted to the management of shell shock or, as he preferred to call this condition, the war neuroses. He viewed it as a medical condition that resulted from an unconscious attempt to escape from an intolerable situation and that was characterized by a conflict between the instinct of self-preservation and the social and ethical demands of military duty.32 He detailed plans for the management of war neuroses through a three-tier treatment system. Treatment had to commence as soon as possible after the onset of symptoms by psychiatrists placed “as near the front as military exigency will permit.”33 Treatment had to be initiated in or near casualty clearing stations, which were located a few miles behind the lines. Here, nervous soldiers would be given a period of rest, sedation, and adequate food. Through persuasion and suggestion in an atmosphere exuding optimism, military physicians would explain to soldiers that their condition was normal and would disappear in a few days. The second tier consisted of psychiatric and neurological wards in base hospitals, which were located five to fifteen miles behind the lines. There, soldiers would be treated for up to three weeks. The third tier consisted of a hospital exclusively devoted to the treatment of war neuroses, which would be located about fifty miles from the front line. Severe types of shell shock were treated there for up to six months. If there was no improvement during this period, soldiers were repatriated and placed in mental hospitals at home. The experience of the Great War had a profound effect on American mental hygiene. First, mental retardation appeared to be relatively unimportant as a cause of nervous breakdown in the armed forces. After the war, it was no longer a central concern of the National Committee. Second, it was found that the most important psychiatric condition contributing to the loss of manpower was psychoneurosis rather than mental illness and feeblemindedness. Individuals suffering from neuroses were rarely found in mental hospitals, yet the social costs of this condition appeared to be quite high. The National Committee consequently focused its attention on the neuroses rather than on mental retardation and chronic forms of mental illness. Third, analogous to the way in which treatment facilities had been organized during the war, mental hygiene psychiatrists argued that psychiatric treatment needed to be provided in the community, as soon as possible after the first symptoms of mental distress had presented themselves. Existing mental hospitals needed to be supplemented by a network of outpatient clinics.34 Salmon aspired to set up such a network for the treatment of veterans with psychiatric problems, which could then serve as a model for the organization of mental health care in general.35

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Child Guidance: Mental Hygiene in the 1920s According to a variety of psychiatric theories, childhood was the period in life in which the seeds for later mental problems were sown. William Alanson White, one of the prime ideologues of the mental hygiene movement and superintendent of (the federal) St. Elizabeths Hospital for the Insane in Washington, DC, stated that childhood was the “golden period for mental hygiene” and urged mental hygienists to focus their attention on its specific problems.36 During the 1920s, mental hygienists developed preventive intervention strategies focused on children. Of these, child guidance clinics were the most successful. Mental hygienists also focused on teacher education and educational reform, which they hoped would promote the mental health of children attending school. They continued their activities in public health education, although these programs now focused on parents and issues related to childrearing. Starting in 1909, psychiatrist William Healy and psychologist Augusta Bronner had operated a psychiatric clinic in association with juvenile courts, first in Chicago and later in Boston. They were inspired by progressive approaches to crime that advocated rehabilitation rather than punishment and retribution. They advocated an individualized and psychiatric approach to juvenile delinquents, which would correct the unique constellation of factors in the lives of young offenders to prevent them from becoming habitual criminals.37 Starting in 1922, the Commonwealth Fund established a five-year program for the prevention of delinquency, administered by the NCMH, through which a great number of child guidance clinics were established.38 In these clinics, a team consisting of a psychiatrist, a psychologist, and a psychiatric social worker assessed the condition of children who had been referred for examination and developed a treatment plan. Initially, child guidance clinics treated children referred by courts for juvenile delinquents, schools, social agencies, physicians, and, in a few cases, parents. They focused on socially disruptive behavior and other more or less minor forms of delinquency, aggression, truancy, and other misdemeanors. During the 1920s, child guidance clinics loosened their association with juvenile courts and increasingly focused on the treatment of the emotional problems of middle-class children. Instead of treating working-class children who were troublesome and disruptive, they now focused on children with emotional problems such as enuresis, disobedience, and temper tantrums. In 1927, the program of the Commonwealth Fund changed course and focused on the training of qualified practitioners to staff the clinics. Through grants and the development of training programs, it stimulated the growth of the specialization of child psychiatry and advanced training in psychiatric social work.39

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The American child guidance clinics provided an example for the international development of psychiatric clinics focused on children. Psychiatrists and social workers from a number of countries received training at child guidance clinics in the United States. The Commonwealth Fund provided funding for initiatives in the United Kingdom, which included the establishment of clinics and the development of the program for the training of psychiatric social workers at the London School of Economics. It provided fellowships for advanced training in the United States to more than forty psychiatric social workers and psychiatrists. Despite its close association with the U.S. National Committee and American child guidance clinics, child guidance and child psychiatry in Britain developed a unique character.40 Social workers and psychiatrists from many other countries visited the United States to observe the operation of child guidance clinics or to receive training. During World War I, the psychiatrists of the National Committee encouraged the development of psychiatric social work as a specialization within social work to alleviate the shortage of mental hygiene workers. In 1918, the Smith School of Social Work in Northampton, Massachusetts started to offer training in social work, an initiative soon followed by other training programs.41 During the 1920s, the profession of social work as a whole adopted a psychological framework based on the method of social case work, a psychological version of the individualized and moralistic approach to poverty that had been practiced by the so-called friendly visitors to the poor, which emphasized moral uplift and self-sufficiency instead of financial aid or economic reform.42 During the conservative 1920s, psychological approaches appeared politically neutral and aided the professionalization of social work. Psychiatric social workers found employment in outpatient clinics, social service bureaus, and child guidance clinics. Through grants from the Commonwealth Fund, the New York School of Social Work provided extensive training in psychiatric social work focused on child guidance.43 Because schoolteachers were in daily contact with growing children, mental hygienists developed programs to educate teachers on the principles of mental hygiene.44 Initially, they aimed to enable teachers to recognize the early signs of maladjustment, which could guide remedial intervention. Later, a number of advocates of progressive education, many of whom were inspired by the work of John Dewey, recognized the similarity between mental hygiene ideas and those of their own.45 They argued that schools should abandon rote learning and rigid discipline, and instead stimulate pupils to become actively involved in their own education through project learning. Personality development should become the central goal of education.46 The Laura Spelman Rockefeller Foundation funded the establishment of a number of laboratory nursery schools, where children could be observed systematically to further the science of child development.47 The educational methods developed in these experimental nursery schools could be implemented in nursery schools nationwide.

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During the 1920s, American interpretations of psychoanalysis came to dominate the mental hygiene movement.48 The reception of psychoanalysis was selective: Mental hygienists did not see an inherent conflict between individual drives and the demands of civilization; instead, they developed a highly normative conception of mental health in which adjustment, social conformity, and social integration were essential elements. Mental health was seen as the unconditional acceptance of prevailing social norms; maturity and mental health could be measured by the degree to which the individuals had internalized these norms and viewed it as the highest form of self-realization to contribute to the greater good. In addition, they also emphasized rationality and the powers of the ego to manage emotions, sexuality, and unconscious desire. In many respects, mental hygienists were inspired by Paul Dubois rather than Sigmund Freud. In his rational psychotherapy, Dubois appealed through rational persuasion and suggestion to the inherent powers of the personality to overcome obstacles: “the object of treatment ought to be to make the patient master of himself: the means to this end is the education of the will, or, more exactly, of the reason.”49 In Dubois’s perspective, strengthening reasoning, personal autonomy, and the ability to act were central. American mental hygienists emphasized rationality, will, and action over emotion, catharsis, and repression. In this conception, psychotherapy aided individuals to face the facts squarely and help them develop an action plan to deal with life’s challenges. This approach fitted with the modernist discourse in the 1920s, which emphasized the necessity of facing the nasty facts of life, to do away with Victorian evasiveness and Pollyanic embroidery.50 Apart from having its roots in the emotional problems of childhood, mental hygienists were convinced that maladjustment was also caused by what was then called the problem of cultural lag.51 According to the advocates of the theory of cultural lag, science and modern technology had profoundly transformed and modernized American society. Ideas on child rearing and human behavior lagged behind these developments and appeared to stem from preindustrial and Victorian times. In this perspective, the problem of maladjustment resulted from the mismatch between old-fashioned childrearing ideas and the conditions of modern life. The prime task of mental hygiene was to develop a science of human nature that could replace these old-fashioned ideas with modern and scientific ones. When successful, mental hygienists would equip the next generation with the right habits and mind-set for the modern age, which was characterized by rationality, efficiency, action, and adjustment. In this perspective, psychiatry was a tool of modernity by bringing the “mind up to date.”52 In 1930, the first International Congress for Mental Hygiene was held in Washington, DC.53 The congress provided the psychiatrists of the National Committee with a unique opportunity to present their ideas and approaches

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to a world-wide audience. Around forty-three hundred delegates from fiftythree countries attended; many of them represented their national mental hygiene organizations. The congress stimulated the further development of psychiatry in many Western countries.

Mental Hygiene as Community Organization: The 1930s The unprecedented economic downturn during the Depression inspired mental hygienists to advocate the establishment of community mental health programs to alleviate the widespread unhappiness, tension, anxiety, and depression of the time. According to them, the emotional costs of the Depression made mental hygiene initiatives more urgent than ever. The justification for mental hygiene initiatives changed decisively during this period. Because of the widespread social turmoil and the perception that society itself was sick, the ideal of adjustment was no longer tenable. Mental hygienists redefined adjustment in terms of inner or emotional adjustment; mental health was no longer defined in terms of social adjustment but viewed in terms of emotional maturity. By maintaining an emotional equilibrium, which would prevent personal frustration from developing into aggression, further social disorder could be prevented. Apart from advocating different intervention strategies, the psychological perspective on mental health enabled mental hygienists to critique social arrangements as inherently repressive because their demands were contrary to those of mental health. Social adjustment could now count as a sign of inner, emotional maladjustment. In 1933, the National Committee published Morale: The Mental Hygiene of Unemployment, written by George K. Pratt, a Rankian psychoanalyst. This booklet aimed to guide relief workers, social workers, and others designing programs to relieve “emotional strains and raise the morale of those who are made insecure.”54 Pratt explained that unemployment affected mental health because it imposed strains and anxieties while the outlets for pent-up emotions, normally available through work, were no longer available. To maintain a healthy outlook on life, Pratt claimed, it was necessary to feel emotionally secure, which he defined as the feeling of belonging to one’s family, one’s neighborhood, and one’s community. With so many individuals out of work, alternative means had to be designed to achieve these ends with the assistance of social workers and others who had the welfare of the nation at heart. Pratt emphasized the importance of work for mental health and therefore advocated public work programs over monetary relief. During the 1920s, the ability to hold down a job was seen as a central characteristic of mental health. Pratt, however, saw the importance of employment as merely instrumental: it provided emotional satisfaction. When no work was available, Pratt argued that the community should provide alternative outlets for pent-up emotions.

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Following his interpretation of psychoanalytic principles, Pratt argued that “a vigorous draining-off or even an explosion of nervous energy . . . seems to be essential for thoroughly normal living.” In this respect, “organized group recreation” such as “pageants, spectacles of one sort or another, historical episodes, parades, boxing matches, and generous showing of movies” could provide the appropriate outlets. Other “old-fashioned interests such as group games, community singing, neighborhood socials, and those other activities so recently scorned as ‘Victorian,’” could also help provide a sense of community. Additional necessary elements of a community mental hygiene program were “public playgrounds, athletic fields, parks, amusement facilities, municipal golf links, concerts and operas, as well as a wide variety of athletic contests, including boxing, baseball, football, etc. Indoor recreational centers likewise are indispensable.”55 Pratt saw a decisive role for the mental hygiene movement to bolster morale and safeguard the mental health of the nation. He was aware that his proposals for community mental hygiene programs involved elements that, “until very recently, have seldom been thought of as having anything to do with mental hygiene.”56 In Pratt’s perspective, mental hygiene was equivalent to community organization.57 There was hardly any role for psychiatry to play in the form of individualized psychotherapy, first because there were so many distressed individuals and, second, because it appeared that the ultimate causes of much distress were economic in nature. Pratt advocated the expansion of mental health services rather than social reconstruction. A number of other psychiatrists similarly advocated the extension of mental health care services.58 These ideas were later incorporated by the community mental health movement. Pratt’s views also illustrate the increasing influence of psychoanalytic ideas on the mental hygiene movement. During the 1930s, mental hygienists no longer focused on social adjustment, conformity, and the potential role of mental hygiene to bolster social cohesion and prevent social disintegration. Instead, they emphasized the importance of inner or emotional adjustment and the importance of family dynamics in its development. During the 1930s, a great number of European psychoanalysts, fleeing the threat of Nazism, migrated to the United States, strengthening the existing psychoanalytic movement there.59 Mental hygienists increasingly focused on emotional conflict, childhood sexuality, and, in particular, on the adverse influence of overprotective and rejecting mothers on young children.60 They no longer viewed it as their role to foster social conformity to maintain the social order. Instead, they focused on the intrapsychic conflict and on the emotional dynamics of family life, which was emphasized after the war as a way to maintain international peace and to foster democratic personalities.61 A healthy emotional development of individuals was seen as essential for preventing war and promoting world peace and international citizenship.

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At the same time, defining mental health in psychological terms allowed mental hygienists to critique current social arrangements because they were not conducive to mental health. A small number of mental hygienists, first and foremost Frankwood E. Williams, who had been the second medical director of the National Committee (1922–31), came to embrace Soviet Communism as the only way to safeguard mental health.62 According to Williams, one could not expect American society, characterized by exploitation and competition, to foster mental health. The Soviet Union, on the contrary, was conducting the most interesting experiment in mental health by organizing a society that had eliminated competition and united the population with a shared purpose, the welfare of all. According to Williams, the Soviets had achieved, “on a mass scale what can only be accomplished in America by a long and expensive process of psychoanalysis, individual by individual.”63 Williams’s rosy views of life in the Soviet Union reflected his desire to fulfill the ideals of social engineering that constituted the utopian basis of the mental hygiene movement. In the 1930s and early 1940s, a variety of psychiatric perspectives on the nature of Western society and its ramifications for mental health were formulated. Psychiatrists, sociologists, and anthropologists interested in the relationship between culture and personality formulated an implicit critique on the repressive nature of American society.64 Already in the 1930s, Margaret Mead claimed that in several primitive societies, adolescence was not a period of Sturm und Drang, and that attitudes toward sexuality were considerably more relaxed elsewhere.65 Mead did not shy away from making general statements about the nature of American society.66 Ruth Benedict, in her Patterns of Culture, claimed that neuroses and psychoses have cultural rather than psychological origins.67 According to the psychiatrist Abram Kardiner, who collaborated with several anthropologists, every culture could be characterized by a modal or basic personality structure, which is nurtured through child rearing practices specific to that culture.68 Standards of normality and mental health were culturally specific. Mental health was adjustment to a specific cultural environment and therefore different cultural environments demanded different adjustment strategies and made different demands on the human personality. Western society made demands that were at times very difficult to fulfill, which led to a number of psychological problems specific to modern individuals. At the same time, a number of psychoanalysts were investigating the relationship between Western society, the specific personality patterns it produced, and the specific neuroses it caused. According to Karen Horney, Western individuals, raised in a society characterized by competition and a pressure for social advancement, suffered from a neurotic tension between the desire to compete and a fear for the loss of love and affection.69 Erich Fromm described the predicament of Western culture as the successful

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attempt to gain freedom from social institutions such as the church, the government, and capitalism, which, unfortunately, brought with it powerlessness and anxiety. In reaction to the frightening new freedom, modern individuals could either follow authoritarian power figures, engage in destructive violence, or become anonymous conformists in the mass culture of the machine, losing one’s identity and the capacity for subjective experience.70 The transformation of Western culture would be essential to maintaining mental health and would stave off the dangers of a mass society populated by atomic consumers who would be easy to manipulate. After World War II, the ideas formulated by mental hygienists during the Depression became influential in the community mental health movement.71 Apart from opening community mental health centers that would make mental health services available to a greater number of people, postwar psychiatrists at times aired social and political views related to mental health.72 Social critiques that analyzed the status of modern individualism, mass society, and conspicuous consumption, of which The Lonely Crowd was a pioneer, appeared with great regularity after World War II. At the same time, a small number of psychiatrists started to doubt the effects of mental hygiene initiatives. Because they were convinced that the personal difficulties of individuals were rooted in social and cultural conditions, mental hygiene interventions only addressed symptoms rather than causes. A widespread interest in mental hygiene therefore only indicated the profoundness of the modern malaise and did not provide a solution.73 These ideas naturally posed a problem to mental hygienists: they were able to trace the social conditions that adversely affected mental health, but the approaches that had been developed thus far only promised to exacerbate the problem. This situation provided a renewed impetus to develop structural approaches to prevention and the promotion of mental health, although these proposals generally remained vague and impracticable.

Conclusion In 1948, the International Congress on Mental Health was held in London, attracting more than two thousand five hundred delegates from sixty countries.74 American and British psychiatrists dominated the program. At this meeting, the World Federation of Mental Health was founded.75 The congress, organized under the theme “mental health and world citizenship,” focused on the importance of mental health to maintain peace and prevent a third world war.76 Conference participants advocated that psychiatry take a central role in the reconstruction of countries ravaged by war. They also emphasized the importance of developing mental health care initiatives to address the malaise of individuals who had been adversely affected by their

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wartime experiences. Through this conference, and by propagating new psychiatric research and intervention practices, mental hygiene psychiatrists aimed not only to further the development of psychiatry worldwide. Revealing the utopian impulse that had been present in the mental hygiene movement from the beginning, they connected the fate of civilization and humankind to the adroit application of psychiatric principles to the problems inherent in modern life. Mental hygienists have left a lasting mark on the development of psychiatry in the Western world. Guided by the ideal of prevention, mental hygienists broadened the domain of psychiatry beyond the treatment of severe and persistent forms of mental illness in mental hospitals to include the treatment, within community-based clinics, of a wide variety of problems. In the process, they broadened the scope of psychiatry by including a variety of problems, neuroses, and forms of social and emotional maladjustment within its disciplinary purview. Mental hygienists attempted to interest as many individuals as possible in their ideas and persuaded physicians, social workers, and teachers to adopt their perspectives. Through their publications, training opportunities, and international congresses, the psychiatrists of the NCMH made their ideas available on an international scale. Psychiatrists worldwide received the main ideas of the mental hygiene movement and selectively incorporated them in their own programs. Mental hygienists were interested in the social aspects of mental illness, mental disorder, and mental health; in general, they were interested in the material, psychological, social, and moral conditions for individuals to exercise the duties and obligations of citizenship. By emphasizing their potential contributions to quelling social disorder and increasing social cohesion, mental hygienists hoped to build up a broad base of support. Because views on the nature of citizenship changed considerably between 1910 and 1945, mental hygiene ideas changed as well. From an emphasis on social behavior that displayed an unconditional acceptance of prevailing norms and values, mental hygienists came to emphasize the importance of the emotional stability and maturity of individuals irrespective of their social behavior. The psychological approach advocated by mental hygienists during the 1950s found broad resonance outside the mental hygiene movement and became part and parcel of American social thought after World War II.77

Notes The quotation in the title of this chapter is derived from Edward A. Strecker, Beyond the Clinical Frontiers: A Psychiatrist Views Crowd Behavior (New York: W. W. Norton & Co., 1940). 1. The founding of the NCMH followed the publication, in 1908, of the autobiography of Clifford W. Beers, who had been an inmate of several mental

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hospitals for a period of three years. See Clifford W. Beers, A Mind that Found Itself: An Autobiography, 3rd ed. (New York: Longmans, Green and Co., 1913). For a biography of Beers and his association with the NCMH, see Norman Dain, Clifford W. Beers: Advocate for the Insane (Pittsburgh: Pittsburgh University Press, 1980). 2. John C. Burnham, “The Struggle Between Physicians and Paramedical Personnel in American Psychiatry, 1917–41,” Journal of the History of Medicine and Allied Sciences 29 (1974): 97. 3. About mental hygiene in the United Kingdom, see Nicholas Rose, The Psychological Complex: Social Regulation and the Psychology of the Individual (London: Routledge, 1985), 158–64; on Robert Sommer and the establishment of the German association, see Volker Roelcke, “‘Prävention’ in Hygiene und Psychiatrie zu Beginn des 20. Jahrhunderts: Krankheit, Gesellschaft, Vererbung und Eugenik bei Robert Sommer und Emil Gotschlich,” in Die Medizinische Fakultät der Universität Giessen: Institutionen, Akteure und Ereignisse von der Gründung 1607 bis ins 20. Jahrhundert, ed. Ulrike Enke (Stuttgart: Franz Steiner, 2007), 395–416. See also Bernd Walter, Psychiatrie und Gesellschaft in der Moderne: Geisteskrankenfürsorge in der Provinz Westfalen Zwischen Kaiserreich und NS-Regime (Paderborn: Verlag Ferdinand Schöningh, 1996). 4. Mathew Thomson, “Mental Hygiene as an International Movement,” in International Health Organizations and Movements, 1918–1939, ed. Paul Weindling (Cambridge: Cambridge University Press, 1995), 286. 5. The psychiatrist Theodore Lidz summarized the prevailing attitude among his colleagues in “Adolf Meyer and the Development of American Psychiatry,” American Journal of Psychiatry 123 (1966–67): 320–32. For a short biography see Ruth Leys, “Adolf Meyer: A Biographical Note,” in Defining American Psychology: The Correspondence between Adolf Meyer and Edward Bradford Titchener, ed. Ruth Leys and Rand B. Evans (Baltimore: The Johns Hopkins University Press, 1990). See also Ruth Leys, “Types of One: Adolf Meyer’s Life Chart and the Representation of Individuality,” Representations 34 (1991): 1–28. 6. Gerald N. Grob, Mental Illness and American Society, 1875–1940 (Princeton: Princeton University Press, 1983), 114. 7. Eunice E. Winters, “Adolf Meyer’s Two and a Half Years at Kankakee: May 1, 1893–November 1, 1895,” Bulletin for the History of Medicine 40 (1966): 441–58. 8. See, for example, Adolf Meyer, “The Dynamic Interpretation of Dementia Praecox,” American Journal of Psychology 21 (1910): 2–3, 139–57; Adolf Meyer, “Fundamental Conceptions of Dementia Praecox,” British Medical Journal 2 (29 September 1906): 757–64; Adolf Meyer, “The Role of Mental Factors in Psychiatry,” American Journal of Insanity 65 (1908): 39–52. 9. For a discussion of Kraepelin’s influence on Meyer, see Adolf Meyer, The Commonsense Psychiatry of Adolf Meyer: Fifty-Two Selected Papers, ed. Alfred Lief (New York: McGraw-Hill, 1948), 82–84. 10. For a characterization of Kraepelin’s approach, see Volker Roelcke, “Biologizing Social Facts: An Early 20th Century Debate on Kraepelin’s Concepts of Culture, Neurasthenia, and Degeneration,” Culture, Medicine, and Psychiatry 21 (1997): 385–89. 11. For typical statements, see Adolf Meyer, “Thirty-Five Years of Psychiatry in the United States and Our Present Outlook [Presidential Address to the American Psychiatric Association],” American Journal of Psychiatry 85, no. 1 (1928): 1–31.

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12. Nathan G. Hale, Jr., The Rise and Crisis of Psychoanalysis in the United States: Freud and the Americans, 1917–1985, Freud in America, vol. 2 (Oxford: Oxford University Press, 1995). 13. Adolf Meyer, “British Influences in Psychiatry,” in The Commonsense Psychiatry of Adolf Meyer, ed. Alfred Lief (New York: McGraw-Hill, 1948), 25–35. This essay first appeared in the Journal of Mental Science in 1933. 14. Heinz-Peter Schmiedebach and Stefan Priebe, “Social Psychiatry and Open Psychiatric Care in Late 19th and Early 20th Century Germany,” in Psychiatrie im 19. Jahrhundert: Forschungen zu Institutionen, Praktiken und Kontroversen im deutschsprachigen Raum, ed. Eric J. Engstrom and Volker Roelcke (Basel: Schwabe, 2003), 263–81; Eric J. Engstrom, Clinical Psychiatry in Imperial Germany: A History of Psychiatric Practice (Ithaca: Cornell University Press, 2003), 189–98. 15. See, for example, Adolf Meyer, “After-Care and Prophylaxis,” [New York] State Hospital Bulletin 1, no. 4 (1909): 631–53. 16. For psychopathic hospitals see Grob, Mental Illness, 135–43. For an in-depth study of the Boston Psychopathic Hospital, see Elizabeth Lunbeck, The Psychiatric Persuasion: Knowledge, Gender, and Power in Modern America (Princeton: Princeton University Press, 1994). 17. Thomas W. Salmon, “Some New Fields in Neurology and Psychiatry,” Journal of Nervous and Mental Diseases 46, no. 2 (1917): 91. 18. Lyndsay A. Farrell, The Origins and Growth of the English Eugenics Movement, 1865–1925 (New York: Garland, 1985); Daniel J. Kevles, In the Name of Eugenics: Genetics and the Uses of Human Heredity (Berkeley and Los Angeles: University of California Press, 1985). 19. Henry Herbert Goddard, The Kallikak Family (New York: MacMillan, 1912). For one of the better-known critiques of this work see Stephen Jay Gould, The Mismeasure of Man, rev. ed. (New York: W. W. Norton & Co., 1996). 20. Aaron J. Rosanoff, “Survey of Mental Disorders in Nassau County, New York, July–October 1916,” [New York State] Psychiatric Bulletin 2 (April 1917): 107–231. 21. Frankwood E. Williams and Victor V. Anderson, Report of a Mental Hygiene Survey of New York County Jails and Penitentiaries, with Recommendations (New York: NCMH, 1924). 22. Ian R. Dowbiggin, Keeping America Sane: Psychiatry and Eugenics in the United States and Canada, 1880–1940 (Ithaca: Cornell University Press, 1997). 23. Wendy Kline, Building a Better Race: Gender, Sexuality, and Eugenics from the Turn of the Century to the Baby Boom (Berkeley and Los Angeles: University of California Press, 2001). 24. Dain, Beers, 277–78. 25. Volker Roelcke, “Continuities or Ruptures? Concepts, Institutions, and Contexts of Twentieth-Century German Psychiatry and Mental Health Care,” in Psychiatric Cultures Compared: Psychiatry and Mental Health Care in the Twentieth Century, ed. Marijke Gijswijt-Hofstra et al. (Amsterdam: Amsterdam University Press, 2005), 162– 82. Gustav Kolb, Hans Roemer, and Rudolf Sommer had been active in the Deutscher Verband from its founding. In 1933, the society was renamed Deutscher Verband für Psychische Hygiene und Rassenhygiene. See also Ernst Rüdin, “The Significance of Eugenics and Genetics for Mental Hygiene,” in Proceedings of the First International Congress on Mental Hygiene, vol. 1, ed. Frankwood E. Williams (New York: ICMH, 1932).

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26. The secondary literature on shell shock in the British army is extensive; see, for example Martin Stone, “Shell-Shock and the Psychologists,” The Anatomy of Madness, ed. William F. Bynum, Roy Porter, Michael Shepherd (London: Tavistock, 1985), 242–71; Ted Bogacz, “War Neurosis and Cultural Change in England, 1914–22: The Work of the War Office Committee of Enquiry into ‘Shell-Shock,’ ” Journal of Contemporary History 24 (1989): 227–56; Chris Feudtner, “‘Minds the Dead Have Ravished’: Shell Shock, History, and the Ecology of Disease-Systems,” History of Science 31 (1993): 277– 420; Peter Leese, Shell Shock: Traumatic Neurosis and the British Soldiers of the First World War (New York: Palgrave MacMillan, 2002); Ben Shephard, A War of Nerves: Soldiers and Psychiatrists, 1914–1994 (London: Jonathan Cape, 2000). For the German response see Paul F. Lerner, Hysterical Men: War, Psychiatry, and the Politics of Trauma in Germany, 1890–1930 (Ithaca: Cornell University Press, 2003). For an overview of the history of psychiatric thinking on trauma, in which several countries are represented, see Mark S. Micale and Paul Lerner, eds., Traumatic Pasts: History, Psychiatry, and Trauma in the Modern Age, 1870–1930 (Cambridge: Cambridge University Press, 2001). 27. The results were published as: Mabel Webster Brown and Frankwood E. Williams, Neuropsychiatry and the War: A Bibliography with Abstracts (New York: War Work Committee, NCMH, 1918); Mabel Webster Brown and Frankwood E. Williams, Neuropsychiatry and the War: A Bibliography with Abstracts, Supplement I, October 1918 (New York: War Work Committee, NCMH, 1918). 28. Earl D. Bond and Paul O. Komora, Thomas W. Salmon: Psychiatrist (New York: W. W. Norton & Co., 1950), 83. 29. This comment was made by Edward A. Strecker, “Military Psychiatry: World War I, 1917–1918,” in One Hundred Years of American Psychiatry, ed. J. K. Hall (New York: Columbia University Press for the American Psychiatric Association, 1944), 386. Salmon’s report appeared as Thomas W. Salmon, War Neuroses (‘Shell Shock’) (New York: War Work Committee, NCMH, 1917); parts of this report were published separately in psychiatric journals. 30. See also Hans Pols and Stephanie Oak, “War and Military Mental Health: The United States Psychiatric Response in the Twentieth Century,” American Journal of Public Health 96 (2007): 2132–42. 31. Salmon, War Neuroses, 47. 32. Ibid., 7. See also John T. MacCurdy, “War Neuroses,” [New York State] Psychiatric Bulletin 2, no. 3 (1917): 243–54; John T. MacCurdy and William H. R. Rivers, War Neuroses (Cambridge: Cambridge University Press, 1918); Sidney I. Schwab, “The Experiment in Occupational Therapy at Base Hospital 117, AEF,” Mental Hygiene 3, no. 4 (1919): 586–93; Schwab, “The Mechanism of the War Neuroses,” Transactions of the American Neurological Association 45 (1919): 177–83; Schwab, “The War Neuroses as Physiologic Conservations,” Archives of Neurology and Psychiatry 1, no. 5 (1919): 579–635. Schwab and MacCurdy worked with Salmon in Base Hospital 117. 33. Thomas W. Salmon, “Care and Treatment of Mental Diseases and War Neuroses (‘Shell Shock’) in the British Army,” Mental Hygiene 1, no. 4 (1917): 542. 34. See, for example, Salmon, “Psychiatric Lessons from the War,” Transactions of the American Neurological Association 45 (1919): 151–53; Salmon, “Some New Fields in Neurology and Psychiatry,” 90–99. 35. These efforts were, for a variety of reasons, not very successful. See Caroline Cox, “Invisible Wounds: The American Legion, Shell-Shocked Veterans, and American

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Society, 1919–1924,” in Traumatic Pasts: History, Psychiatry, and Trauma in the Modern Age, 1870–1930, ed. Mark S. Micale and Paul Lerner (Cambridge: Cambridge University Press, 2001), 280–305. 36. William A. White, “Childhood: The Golden Period for Mental Hygiene,” Mental Hygiene 4, no. 2 (1920): 257–67; William A. White, The Mental Hygiene of Childhood (Boston: Little Brown, 1919). For an overview of mental hygiene ideas in the 1920s see Theresa Richardson, The Century of the Child: The Mental Hygiene Movement and Social Policy in the United States and Canada (Albany: State University of New York Press, 1989). 37. William Healy, The Individual Delinquent: A Textbook of Diagnosis and Prognosis for All Concerned in Understanding Offenders (Boston: Little, Brown, 1915). 38. For a history of child guidance see Margo Horn, Before It’s Too Late: The Child Guidance Movement in the United States, 1922–1945 (Philadelphia: Temple University Press, 1989); Kathleen Jones, Taming the Troublesome Child: American Families, Child Guidance, and the Limits of Psychiatric Authority (Cambridge, MA: Harvard University Press, 1999). 39. Alice Boardman Smuts, Science in the Service of Children, 1893–1935 (New Haven: Yale University Press, 2006), 207–25. 40. Deborah Thom, “Wishes, Anxieties, Play, and Gestures: Child Guidance in Interwar England,” in In the Name of the Child: Health and Welfare, 1880–1940, ed. Roger Cooter (London: Routledge, 1992), 200–19; Smuts, Science in the Service of Children, 219–25; Bonnie Evans, Shahina Rahman, and Edgar Jones, “Managing the ‘Unmanageable,’” Interwar Child Psychiatry at the Maudsley Hospital, London,” History of Psychiatry 19 (2008): 454–75. 41. For a history of social work see Roy Lubove, The Professional Altruist: The Emergence of Social Work as a Career, 1880–1930 (New York: Atheneum, 1965); John H. Ehrenreich, The Altruistic Imagination: A History of Social Work and Social Policy in the United States (Ithaca: Cornell University Press, 1985); Daniel J. Walkowitz, Working with Class: Social Workers and the Politics of Middle-class Identity (Chapel Hill: University of North Carolina Press, 1990). 42. See Mary E. Richmond, Friendly Visiting among the Poor: A Handbook for Charity Workers (New York: MacMillan, 1899) and Mary E. Richmond, What Is Social Case Work? An Introductory Description (New York: Russell Sage Foundation, 1922). 43. Martha Morrison Dore, “The Retail Method of Social Work: The Role of the New York School in the Development of Clinical Practice,” Social Service Review 73, no. 2 (1999): 168–90. 44. William A. Burnham, The Normal Mind: An Introduction to Mental Hygiene and the Hygiene of School Instruction (New York: Appleton, 1924). 45. For Dewey’s ideas on functional psychology, the philosophy of pragmatism, and educational reform, see Steven C. Rockefeller, John Dewey: Religious Faith and Democratic Humanism (New York: Columbia University Press, 1991). See also Emily D. Cahan, “John Dewey and Human Development,” Developmental Psychology 28, no. 2 (1992): 205–14. 46. Sol Cohen, “The Mental Hygiene Movement and the Development of Personality: Changing Conceptions of the American College and University, 1920–1940,” History of Higher Education, Annals 2 (1982): 65–101; Cohen, “The Mental Hygiene Movement, the Development of Personality and the School: The

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Medicalization of American Education,” History of Education Quarterly 23 (1983): 123–48; Cohen, “The School and Personality Development: Intellectual History,” in Historical Inquiry in Education: A Research Agenda, ed. J. H. Best (Washington, DC: American Educational Research Association, 1983), 109–37. 47. Smuts, Science in the Service of Children, 155–72; for an overview of educational experiments conducted by mental hygienists in Canada see Hans Pols, “Between the Laboratory and Life: Child Development Research in Toronto, 1919–1956,” History of Psychology 5, no. 2 (2002): 135–62. 48. For psychoanalysis in the United States, see Nathan G. Hale, Jr., Freud and the Americans: The Beginnings of Psychoanalysis in the United States, 1876–1917, Freud in America, vol. 1 (Oxford: Oxford University Press, 1971); James Jackson Putnam and Psychoanalysis: Letters between Putnam and Sigmund Freud, Ernest Jones, William James, Sandor Ferenczi, and Morton Prince, 1877–1917, Nathan G. Hale, Jr., ed. (Cambridge, MA: Harvard University Press, 1971); John C. Burnham, Paths into American Culture: Psychology, Medicine, and Morals (Philadelphia: Temple University Press, 1988). 49. Paul Dubois, The Psychic Treatment of Nervous Disorders: The Psychoneuroses and Their Moral Treatment, trans. Smith Ely Jelliffe and William A. White (New York: Funk & Wagnalls, 1905), 35. Both White and Jelliffe became influential psychoanalysts; at the time White was influential in the mental hygiene movement. 50. Ann Douglas, Terrible Honesty: Mongrel Manhattan in the 1920s (New York: Farrar, Straus, and Giroux, 1995). 51. William Fielding Ogburn, Social Change with Respect to Culture and Original Nature (New York: Huebsch, 1922); James Harvey Robinson, The Mind in the Making: The Relation of Intelligence to Social Reform (New York: Harper, 1921). See also Floyd Dell, Love in the Machine Age: A Psychological Study of the Transition from Patriarchal Society (New York: Farrar and Rhinehart, 1930). 52. Robinson, Mind in the Making, 14. 53. For an account see Dain, Beers, chap. 15, “The First International Congress on Mental Hygiene.” See also Frankwood E. Williams, ed., Proceedings of the First International Congress on Mental Hygiene, 2 vols. (New York: ICMH, 1932). See also Thomson, “Mental Hygiene as an International Movement.” 54. George Kenneth Pratt, Morale: The Mental Hygiene of Unemployment: For Unemployment Relief Workers, Social Workers, Public Health and Visiting Nurses, Community Chest Executives, Public Officials, Clergymen and Members of Boards of Philanthropic Organizations (New York: NCMH, 1933). 55. Ibid., 46, 54. 56. Ibid., 60. 57. See George K. Pratt, “Mental Hygiene: A Developing Concept,” Journal of Nervous and Mental Disease 77 (1933): 633–42. 58. Clara Bassett, Mental Hygiene in the Community (New York: Macmillan, 1934); see also Paul V. Lemkau, Mental Hygiene in Public Health (New York: McGraw Hill, 1949). 59. Hale, The Rise and Crisis of Psychoanalysis, 1917–1985. 60. The work of David Levy was central in this respect. See David M. Levy, Maternal Overprotection (New York: Columbia University Press, 1943); Kathleen Jones, “‘Mother Made Me Do It’: Mother-Blaming and the Women of Child Guidance,” in “Bad” Mothers: The Politics of Blame in Twentieth-Century America, ed. Molly Ladd-Taylor and Lauri Umansky (New York: New York University Press, 1998).

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61. The writings of John Dollard and his colleagues on frustration and aggression was central in this respect; see John Dollard, Neal E. Miller, Leondard W. Doob, O. H. Mowrer, Robert R. Sears, Frustration and Aggression (New Haven: Yale University Press for the Yale Institute of Human Relations, 1939). See also Fred Matthews, “The Utopia of Human Relations: The Conflict-Free Family in American Social Thought, 1930–1960,” Journal for the History of the Social and Behavioral Sciences 24 (1983): 343–62. 62. Within social work, a radical movement came into being during the 1930s. See Jacob Fisher, The Response of Social Work to the Depression (Cambridge, MA: Schenkman, 1980). See also Benjamin Harris, “Psychology and Marxist Politics in the United States,” in Psychology and Society: Radical Theory and Practice, ed. Ian Parker and Russell Spears (London: Pluto Press, 1996). 63. Frankwood E. Williams, “The Significance of Dictatorship: Russia and Italy through the Eyes of an American Psychiatrist,” Survey Graphic 68, no. 3 (1 May 1932): 132. For psychiatry and mental hygiene during the Depression, see also Hans Pols, “Divergences in American Psychiatry during the Depression: Somatic Psychiatry, Community Mental Hygiene, and Social Reconstruction,” Journal of the History of the Behavioral Sciences 37, no. 4 (2001): 369–88. 64. John S. Gilkeson, “The Domestication of ‘Culture’ in Interwar America, 1919–1941,” in The Estate of Social Knowledge, ed. JoAnne Brown and David K. van Keuren (Baltimore: The Johns Hopkins University Press, 1991), 153–74; Bert Kaplan, “Personality and Social Structure,” in Review of Sociology: Analysis of a Decade, ed. Joseph B. Gittler (New York: John Wiley & Sons, Inc., 1957), 87–126; Alex Inkeles and Daniel J. Levinson, “National Character: The Study of Modal Personality and Sociocultural Systems,” in Handbook of Social Psychology, ed. Gardner Lindzey and Elliot Aronson (Reading, MA: Addison-Wesley, 1969), 418–506. 65. Margaret Mead, Coming of Age in Samoa (New York: Morrow, 1928); Margaret Mead, Growing Up in New Guinea (New York: Morrow, 1930); Margaret Mead, Sex and Temperament in Three Primitive Societies (New York: Morrow, 1935). 66. Most famous is Margaret Mead, And Keep Your Powder Dry: An Anthropologist Looks at America (New York: Morrow, 1942). 67. Ruth Benedict, Patterns of Culture (Boston: Houghton Mifflin, 1934). 68. See Abram Kardiner and Ralph Linton, The Individual and His Society: The Psychodynamics of Primitive Social Organization (New York: Columbia University Press, 1939); Abram Kardiner et al., The Psychological Frontiers of Society (New York: Columbia University Press, 1945); Abram Kardiner, “The Concept of Basic Personality Structure as an Operational Tool in the Social Sciences,” in The Science of Man in the World Crisis, ed. Ralph Linton (New York: Columbia University Press, 1945), 107–22. 69. Karen Horney, “Culture and Neurosis,” American Sociological Review 1, no. 2 (1936: 221–30; Karen Horney, The Neurotic Personality of Our Time (New York: Norton, 1937). 70. Erich Fromm, Escape from Freedom (New York: Rinehart, 1941); Erich Fromm, The Sane Society (New York: Rinehart, 1955); Erich Fromm, “Individual and Social Origins of Neurosis,” American Sociological Review 9 (1944): 380–84. 71. See Gerald N. Grob, From Asylum to Community: Mental Health Policy in Modern America (Princeton: Princeton University Press, 1991). 72. Hans Pols, “Anomie in the Metropolis: The City in American Sociology and Psychiatry,” Osiris 18 (2003): 194–211.

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73. The first explicit social critique on the mental hygiene movement appeared in 1938 in Harry Stack Sullivan’s journal Psychiatry: Kingsley Davis, “Mental Hygiene and the Class Structure,” Psychiatry 1 (1938): 55–65. C. Wright Mills strongly criticized the class-based nature of mental hygiene advice: Mills, “The Professional Ideology of Social Pathologists,” American Journal of Sociology 49 (1943): 165–80. John Seeley and his colleagues, as an (unexpected) outcome of a research project conducted for the Canadian Mental Health Association, came to similar conclusions. John R. Seeley, R. Alexander Sim, and Elizabeth W. Loosley, Crestwood Heights: A Study of the Culture of Suburban Life (New York: Basic Books, 1956). 74. For the proceedings, see John Carl Flugel, ed., International Congress on Mental Health, London 1948, Proceedings (London: H. K. Lewis, 1948). 75. Eugene B. Brody, The Search for Mental Health: A History and Memoir of the World Federation for Mental Health, 1948–1997 (Baltimore: Williams & Wilkins, 1998). 76. See also Brock Chisholm, “The Reestablishment of Peacetime Society [the William Alanson White Memorial Lectures],” Psychiatry 9 (1946): 3–20. 77. See, for example, T. J. Jackson Lears, No Place of Grace: Antimodernism and the Transformation of American Culture, 1880–1920 (New York: Pantheon, 1981).

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Chapter Seven

Mental Hygiene in Britain during the First Half of the Twentieth Century The Limits of International Influence Mathew Thomson The mental hygiene movement is most commonly associated with an explosion of popular interest in psychology in the United States at the start of the twentieth century.1 The formation of a national association of mental hygiene in 1909 by former mental patient Clifford Beers was one manifestation of this broader enthusiasm.2 Another was the recasting of Freud in a more optimistic, self-improving American idiom, which was at least as important as a national organization when it came to the spread of mental hygiene thought and practice on that side of the Atlantic.3 It is tempting to regard the expansion of “mental hygiene” as a psychiatric discipline across the globe over the next three decades as a direct result of this American example, and thus as a process of the internationalization of psychiatry. Indeed, elsewhere I have developed this very line of analysis in an account that assesses the extent to which we can regard mental hygiene as an international movement during this period.4 That essay also highlighted some of the limits to such a thesis, and in this chapter I will develop a case regarding the limits of international influence in more detail by looking in depth at the development of mental hygiene as a psychiatric discipline in Britain during the first half of the century. From the start, within British psychiatric circles there was suspicion of the two foundation stones of the mental hygiene movement in America: it’s populist and commercial orientation. Even the early British psychoanalyst, Ernest Jones, reported to Freud on his visit to the United States in 1908: “I am not very hopeful of the present wave of interest for the Americans are a

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peculiar nation with habits of their own. . . . Their attitude toward progress is deplorable. They want to hear of the ‘latest’ method of treatment with an eye on the Almighty Dollar and think only of the credit[,] or ‘kudos’ as they call it, it will bring them.”5 There was something vulgar about such a popular and profit-oriented embrace of the psychiatry. However, by the 1930s, mental hygiene organizations had emerged across much of the Western world, including Britain. The model developed in the United States was clearly influential, and Beers took a prominent role in efforts to create an international mental hygiene movement between the wars, but mental hygiene theory and practice also took on distinctive national attributes.6 In Britain, the National Council for Mental Hygiene was founded in 1922. Its first meeting was indeed attended by Beers, who was on a European trip to spread the gospel of mental hygiene. On the same visit he also spoke to the main organization for British psychiatrists, the Medico-Psychological Association.7 Like its North American forebear, the British National Council for Mental Hygiene would publish a journal—Mental Hygiene—that appeared intermittently in the 1930s. In 1942, after several years of discussion and after an influential recommendation in the Feversham Report of 1939 for rationalization of voluntary efforts to promote mental health—and now with wartime priorities papering over rivalries and strategic differences, the National Council amalgamated with four other voluntary organizations in related fields to form the National Association for Mental Health (with a single journal, Mental Health).8 This body would emerge from the war toward the fore of a world movement for the promotion of mental health. The new prominence of the British was marked by the holding of the 1948 International Congress on Mental Health—now “mental health” rather than “mental hygiene”—in London.9 The location chosen was in part a consequence of geopolitical circumstance, in part a consequence of ideology: a British style in mental hygiene, which assumed and advocated a close relationship between democratic values and mental health, fitted in with a broader international climate of opinion at the war’s end. A brief background of the other main organizations in the amalgamation of 1942 will help in understanding the character of the mental hygiene movement in the British context. The most significant was the Central Association for Mental Welfare, a group set up in the aftermath of the Mental Deficiency Act of 1913, initially under the title of the Central Association for Care of Mental Defectives, to address what was at the time regarded here and elsewhere as the most pressing mental problem of the day. Gradually, its interests shifted toward mental health more generally, as reflected in its change of title in 1921 and that of its increasingly influential journal from Studies in Mental Inefficiency to Mental Welfare.10 The second was the Mental After-Care Association, a smaller and less ambitious organization but with the oldest history, reaching back to the 1870s, which was concerned with the

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provision of “after-care” for people leaving mental hospitals.11 The third, the Child Guidance Council, was much newer, offering training and coordination for the child guidance clinics that had been springing up since the late 1920s. Finally, there was the Home and School Council, a group that brought together the interests of educationalists and parents.12 It is important to recognize that although doctors dominated the National Council for Mental Hygiene, the other groups had a predominantly lay membership and a high proportion of women involved as volunteers and nascent psychiatric social workers. American influence was most significant in areas involving professionals: not just psychiatrists, but also the child guidance psychiatric social workers. A significant minority visited the United States and a larger number drew on American models in their training. Where mental hygiene as a discipline emerged out of traditional patterns of social welfare and philanthropy, as was the case in much social work with mental defectives, American ideas and models had less influence. Indeed, writing in the early 1920s, one American social worker noted how the work of the Mental After-Care Association had provided inspiration for the first psychiatric social worker in New York in 1905 but now seemed somewhat old-fashioned and class-based in its reliance on voluntarism and lady almoners.13 The rhetoric of “mental hygiene” certainly took inspiration from the United States. In Britain, the term had its heyday with the publicity surrounding the First International Congress of Mental Hygiene held in Washington, DC in 1930. Even then, and certainly thereafter, the term never captured the imagination in the way that it clearly did in the United States. There was the issue of timing: the existing groups had already chosen titles, and these tended to derive from their active role in providing supervision outside the hospital. A more paternalistic, class-bound philanthropic tradition in Britain, and the significant steps already being taken toward a welfare state in the interwar period, probably also contributed to the persistence here of an emphasis on “care,” or now “welfare.” By the early 1930s, the word “hygiene” was perhaps too suggestive of eugenic sterilization just at the time that the emphasis in public policy and debate was shifting toward breaking down the stigma and the notion of any hard-and-fast division between mental illness and health. At the 1930 Congress, the British saw how such a broader agenda could find itself sidelined by a controversial debate over sterilization, particularly through the intervention of representatives of German “racial hygiene” such as psychiatrist Ernst Rüdin.14 In a British context, where concerns about liberty of the individual were so strong, the phrase “mental hygiene” may simply have struck the wrong tone.15 It was certainly rare in the popular self-help culture of the era. The expression “mental health,” or talk of developing “personality” (drawing inspiration from popular American psychology), had a much more conducive tone. Just as in the British

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eugenics movement of the 1930s, there were strategic reasons for a positive rather than a negative approach.16 Such caveats about using the concept of mental hygiene to talk about British developments in the interwar period are significant, particularly when attempting to think about international comparisons. Nevertheless, the very fact that the various groups came together does point to the emergence of a common agenda toward the close of the interwar period. For the sake of convenience, this essay will use the term mental hygiene as a label for this emerging agenda. What was it then that these groups, and an increasing body of lay and professional opinion, held in common? At a very basic level, this was a movement for reform of both public health policy and opinion. It looked to extend the reach of psychological medicine from the mental illness of the few to the neuroses of the many and the mental health of the whole. In doing so, it looked beyond the traditional focus of the mental asylum to the outpatient clinic and to nonmedical sites within the community such as the school, the court, the factory, and the home. It looked to rescue psychological medicine from the cul-de-sac of the custodial asylum and turn it instead into an instrument for early treatment and prevention.17 The mental hygiene movement adopted four main strategies. First, it promoted concern and action regarding the eugenic basis of mental health in the population as a whole. Second, it developed clinics for treating milder cases of mental disorder on a voluntary, temporary, and outpatient basis. Third, it aimed to educate the public regarding mental health issues and to prevent mental disorder through advice on lifestyle. Finally, it recognized a potential role in advising on the organization of society to prevent mental disorder. This chapter will consider the history of each of these strategies in turn, though the emphasis, mainly because of space constraints, will be on the first two, highlighting their different constituencies of support and the way that their fortunes compared over the interwar period.18 In doing so, it aims to illuminate our understanding of the comparison and interconnections (or lack of interconnections) between British mental hygiene and developments in this sphere in the United States and Germany.

The Eugenic Strategy As already suggested, I want to propose that we deemphasize the significance of eugenics within British mental hygiene. The decision to start my analysis with this strategy may therefore appear somewhat counterintuitive. I have two reasons for doing so. The first is that the annihilationist trajectory of a eugenic-influenced German psychiatric policy makes this difference in British development such an important subject to a transnational project. The second reason is that a eugenic strategy had been more important in

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Britain in the first decades of the century and thus serves as a convenient starting point for considering the shifting nature of British mental hygiene over the period. Up until the First World War eugenics was the main way of articulating a concern about what would come to be called mental hygiene: the existence of mental problems within the community and beyond the boundary of certifiable lunacy; a concern, ultimately, about the relationship between the mental fitness of each individual in relation to that of the nation as a whole. In particular, this period saw the eugenics movement fanning a public panic about the existence of a “feebleminded” section of the population not covered by the existing lunacy legislation. This panic was clearly not confined to Britain. The development of special psychiatric and educational institutions for the feebleminded was particularly well-developed in North America, and attracted considerable attention. In the United States and Canada, the development of special institutions for the feebleminded influenced policy on immigration; something that was absent in the British context. However, in developing proposals for new legislation and special institutions, the British looked to the United States in its use of a “colony” model of care, as is evident in the influential Royal Commission on the Care and Control of the Feebleminded, which reported in 1908. The British, though, tended to talk about this as a problem of “mental deficiency”; the “feebleminded” were simply the highest (intelligence) grade of this group (in America, the “moron”), beneath them in descending order were the “idiots” and “imbeciles.” Britain also looked to the Continent. Germany, however, was not a major influence in this area of psychiatric policy.19 The basis for public anxiety went well beyond mere eugenics, and in fact great care had to be taken to distance the argument for action from a science that was still regarded with a good deal of suspicion.20 But moral and social rationales for action were as difficult to disentangle from eugenics at the time as they have been subsequently for historians trying to make sense of the oddity of a political system priding itself on its respect for the liberty of the subject while at the same time accepting legislation like the Mental Deficiency Act of 1913. Qualifications about broader motivation and the ongoing suspicion of eugenic expertise aside, the new legislation was still a significant achievement for eugenics. Under it, there was an obligation for local authorities to provide for the care and control of patients in new specialized “mental deficiency” institutions. The institutes were to house not only the more mentally impaired “idiots” and “imbeciles,” who were already covered under the nineteenth-century lunacy legislation, but also, and this was where the controversy and the eugenic concern lay, the so-called feebleminded, who were much nearer the borderline of normal intelligence and who had never before been certifiable. The segregation of people with an inborn mental impairment made manifest by low intelligence, and, more

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crucially, in practice, the segregation of people judged to be social, moral, and educational failures, bore the promise of removing an hereditary underclass whose purported sexual profligacy appeared to threaten the mental and thereby the moral and social fitness of the nation as a whole. Lobbying for action, and now with the taste of success behind it, the Eugenics Society, formed in 1907—very much in tandem with the campaign for legislation—accepted the problem of the feebleminded as one of its key concerns. It continued to take an active interest in incarcerating the feebleminded over the next two decades in response to inconsistent and limited implementation of the legislation. However, this active interest was nothing like as clear and effective a rallying cause as had been the initial case for legislation. By the late 1920s, and inspired by the developments in the United States, campaigning energy therefore shifted to introducing a policy of sexual sterilization for mental defectives. Despite signs of significant public, political, and governmental sympathy for sterilization at the start of the 1930s, these efforts came to nothing and the campaign petered out. Politically, concern about opposition from the Catholic church and the Labour movement were both significant hurdles to enacting legislation for compulsory sterilization. Association with Nazi policy was not damming but awareness of flawed practice here and elsewhere in Europe and the United States did little to improve the chances of Britain going down the same route. There was also a legal conundrum: in an effort to overcome libertarian objections, the campaign for sterilization chose to back a voluntary scheme; but, in doing so, it exposed the fallacy that it was targeting a class that was genuinely mentally incapable. As much as anything, the momentum had gone, if it had ever been there in the first place, for approaching the problem of mental hygiene through eugenics. Even so, the British delegation at the 1937 Second International Congress in Paris (led by Laurence Brock, chairman of the government body the Board of Control), while universally criticizing German psychiatrist Ernst Rüdin’s advocacy of compulsory sterilization, still acknowledged the case for a voluntary system to control the fertility of the mentally defective.21 In part, the willingness of British mental hygienists to adopt a more moderate line on sterilization than their colleagues in Germany or the United States goes back to the fact that for all the talk of its limitations, the Mental Deficiency Act of 1913 had managed to segregate (and thereby control the fertility of) a very substantial number of the feebleminded: some forty-six thousand by the end of the 1930s.22 Of course, this preventive measure was not sufficient to match rapidly expanding estimates of the number of people in need of care and control.23 However, the period had also seen the emergence of other forms of care that partly made up for the insufficient number of institutes to house the vast numbers of people thought to be in need of help. The 1913 Act had facilitated the creation

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of a system of supervision in the community, utilizing groups like the Central Association for Mental Welfare and an increasing number of (largely female) social workers, many of whom took on specialist training in mental health care. Such female volunteers and social workers were certainly not immune from advancing a eugenic case for care and control; indeed, if anything, women were notable for their prominence in the campaign for sterilization. But they also served as a bridge to another approach in mental hygiene. The women were dealing with cases that by definition challenged the idea of a hard-and-fast line between mental illness or deficiency and health. A number of female volunteers and social workers also visited the United States and came back with some training in psychotherapy and enthusiasm for psychotherapeutic models. Others benefited from training inspired by the American model that was first set up in Britain at the London School of Economics. Their role as caseworkers led them to situate these cases of feeblemindedness in a social and familial, and not simply a hereditary, context. Support for a policy of eugenic weeding did not fade away altogether, but for women such as these caseworkers it became more of a marginal adjunct to a more ambitious strategy of delivering mental health care in the community to the broader population. When it came to children, we again see the mental deficiency legislation in some ways steering the focus of effort beyond and even away from eugenics. “Cradle to grave” segregation had been a crucial element of the eugenic argument, but in the case of children the libertarian resistance was firmer. Mentally defective children became the responsibility of the education authorities. There turned out to be a reluctance to condemn any child as ineducable, particularly since this would cost more than educating the normal child. Instead, the period saw the mentally defective child acting as a bridgehead for concern about the intelligence and mental health of all schoolchildren. The psychologists with their mental tests, clinics, and influence over pedagogic principles moved into the schools; the defective child, by and large, did not move out.24 Finally, it is also relevant to note the position of the psychiatric profession and the way that it also contributed to a displacement of eugenics as the key mental hygiene strategy. The fact that the discussion has been able to avoid this group for so long is revealing. Psychiatrists, quite simply, were not the key actors in the campaigns for legislation. At the start of the period, they were not in a strong position to place pressure on anybody. They were associated with the most beleaguered area of medicine of the day.25 It may even be a little anachronistic to speak of a psychiatric profession in Britain at this time. Specialist training was only now slowly emerging.26 There was some kind of corporate identity as asylum doctors through the Journal of Mental Science, but most of those working in the field regarded themselves as doctors with a particular type of managerial

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role rather than as mental specialists. The ablest might well move on to a more prestigious area of medicine after a position as an asylum superintendent at the start of their careers. Individual doctors, Alfred Tredgold for instance, may have played important roles in offering expert authority to the case for eugenics, but if we are to equate psychiatry with an involvement in the asylum system, then we find that there were good reasons for being cautious about going down the eugenic line.27 Of course, a few doctors already worked in the field of mental deficiency and were keen to mark it out as the provenance of medicine.28 Nevertheless, desperate to distance their work from stigma, desperate for therapeutic advance, few others saw any great attraction in taking charge of a new system of custodial care for people who were, by definition, incurable. Equally, although there had been some discussion of sterilization amongst asylum superintendents since the start of the century, there was general reticence about association with a policy that could further stigmatize what went on in mental institutions.29 Of course, there were doctors in mental deficiency institutions who had come to recognize their captive populations as useful source material for research. Yet this recognition could reflect an interest in genetics rather than support for eugenics. In the case of someone like Lionel Penrose, the former actually provided ammunition against the latter.30 Potentially, the most attractive thing about the mental deficiency system for the psychiatric profession was that it might act as a valve to relieve other institutions of long-term incurable cases and thereby rescue the mental hospital system as a whole. The problem was that this spoke against the core principle of the 1913 legislation—a need to differentiate the mentally defective and the mentally ill—and therefore movement in this direction was difficult. If psychiatry wanted to become the mental counterpart to general medicine, taking charge of mental deficiency and its eugenic baggage had probably been something of a retrograde step.

The Outpatient Strategy Cut off, like their charges, from easy interaction with the outside world in still largely enclosed and isolated institutions, medical superintendents found it difficult to engage in the second and increasingly the more dynamic mental hygiene strategy of the period. The era saw a fundamental shift in emphasis: from the asylum to the community, and from the mentally ill to people with what at the time were still often called “neuroses” (though gradually and more appropriately, since the origin lay in the mind rather than the physical condition of the nerves, the “psychoneuroses” or “mild psychoses”). The development of this type of mental hygiene system was far more likely to involve doctors whose professional employment lay outside the asylum,

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where they were less likely to work with people with severe mental illness. That said, there is a part of the story that does involve some medical superintendents of asylums. One of the important roots of the British mental hygiene system was the breakdown of the barrier between hospitals and the outside world through the use of social workers—initially volunteers but increasingly salaried and trained personnel. This trend to hire trained professionals to work in the community went back at least as far as the founding of the Mental After-Care Association in the late nineteenth century.31 There would be a significant further development in this direction under the 1913 Mental Deficiency Act, under which supervision in the community, guardianship, and licensing made up for the limits of segregation.32 Although these developments rested on the energy of and the new opportunities for women in the field of social work, they also needed the support of medical superintendents. J. R. Lord, for instance, medical superintendent at Horton Mental Hospital and an important figure in the field of psychiatry as a whole, supported social work as an adjunct to mental hospital care. This support lay behind his role as a founding force in the National Council for Mental Hygiene.33 Female visitors would help to change the atmosphere of the hospital and in getting to know families and employers they would assist in the move toward a more “dynamic” psychiatry.34 Lord’s use of the term dynamic psychiatry suggests the influence of Adolf Meyer in the United States, who was often seen as representing the psychiatric philosophy, if there was one, behind mental hygiene.35 As far as the British context goes, this suggested influence exaggerates Meyer’s significance and more generally the significance of ideas over practice. The British admired him, but as much for the fact that his approach appeared conducive to existing British commonsense eclecticism as for his research in mental hygiene. Visiting the 1930 International Congress on Mental Hygiene in Washington, Lord was clearly impressed by some of the things he encountered: “America,” he acknowledged, “has a mental hygiene message for us.”36 However, he also recognized the danger that the adoption of a mental hygiene program could leave mental hospitals out of the picture and in a worse state than ever. He wanted social work to be under the supervision of the medical superintendent. And he was ambivalent about supporting the full-scale move from amateurism to professionalism, and toward community care as an alternative rather than a mere adjunct to the asylum, which was in fact the real trend of the period, particularly when it came to developments in the field of mental deficiency.37 He hoped that in Britain a mental hygiene program could be forged that integrated the mental hospital and the local community; local people would pay for and as a consequence identify with the care and treatment of their mentally ill and defective members, thus breaking down the isolation and prejudice that currently surrounded the subject.38

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There was good reason for Lord’s optimism in 1930. After several decades of pressing for an easement of the strict legalism that surrounded entry to mental hospitals, the medical profession had at last seen its advice bearing fruit with the passage of the Mental Treatment Act of 1930. Up until then, the mentally ill had to be legally certifiable, and this had meant that it was virtually impossible to handle mental problems in their early stages when treatment might actually have been effective. The opening of the Maudsley Clinic in London seemed to show what was possible as it rapidly emerged in the 1920s as a national center for research and training, paralleling on a more modest scale the model of the psychiatric clinic in Germany and the United States.39 The 1930 Act made it possible to admit people to mental hospitals throughout Britain on a voluntary and temporary basis. It promised to turn the asylum into a place of treatment and cure rather than of long-term custody. The Local Government Act of the same year added to the optimism. A further nail in the coffin of the Poor Law, the act heralded a new age of integrated local services. It also raised the prospect of using some of the old workhouses to accommodate the chronic, long-term, and elderly cases that had come to dominate the asylums and that threatened to hold back their revival as places of psychiatric medicine rather than mere care.40 The optimistic vision was that the mental hospital might emerge as the center of a hub of influence in intimate contact with the broader community.41 Unfortunately, older public attitudes about the mental hospital persisted, and it often proved easier to attract patients if outpatient clinics were within general hospitals. There was also the problem that the average county mental hospital was not likely to have the necessary psychotherapeutic expertise for its new role.42 The government body with responsibility, the Board of Control—a title that itself captures the dilemma of having one foot tied to a custodial past—was rightly concerned about a “cleavage of practice,” in which psychotherapy and the treatment of curable neurosis would be practiced elsewhere.43 What is equally significant is that though a culture of biomedical research was becoming more common in the mental hospitals of the interwar period, as evident in papers submitted to the psychiatric profession’s Journal of Mental Science, there was still a huge gulf between the average mental hospital and a hospital like the Maudsley.44 By 1942, although 83.1 percent of the outpatient clinics treating mental cases had been established after the 1930 Act, it is important to note that just 7.1 percent of these were attached to mental hospitals. The majority, 71 percent, were in voluntary hospitals, and a smaller though still significant proportion of 14.3 percent were in municipal clinics separate from any hospital.45 Such figures support the proposition that the expansion of a mental hygiene program of outpatient care depended more on the interest in mental health care in the broader medical profession and in the broader community than upon the still largely hospital-bound psychiatric profession itself. This survey

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also found that the clinics attached to mental hospitals dealt more with psychotic than with neurotic patients; they were still performing their traditional role, albeit by other means. A “cleavage of practice,” as prophesied by the Board of Control, was indeed taking place; the mental hospital reached out but only tentatively, while the more radical expansion in the scope of mental health care—the move to mental hygiene—was largely outside the scope of psychiatry as previously defined. This did not mean that psychiatry could not redefine itself, that at least some of what went on outside the hospital could not become representative of a new psychiatry. However, if a process of redefinition was to take place it bore the danger of producing a field of work with a deep division of interest running through it. There has been little if any historical attention directed toward what, in numerical terms, was in fact the predominant form of outpatient care in the period. The story of specialization within the voluntary hospitals is not as dramatic as that of the pioneering independent psychotherapeutic clinics or even of the reform of the mental hospital itself. The story may also have been obscured because of the way it was advanced via the confusing and elusive diagnosis of the “neuroses.” Although interwar psychotherapeutic medicine would come to question the very notion of neurosis, implying as it did some hitherto undemonstrated organic basis in the condition of the nervous system, and would suggest the terminology of psychoneuroses or even of mild psychoses as preferable, practice remained very different. “Neurosis,” “nervous breakdown,” and “neurasthenia,” all of these conditions had continuing popular appeal; redefining such conditions as mental illnesses did not. The former gave socially acceptable meaning to suffering; the latter had associations with the stigma of mental illness. However, a growing awareness of psychological theory, as well as the challenge of adjusting to a new relationship with the state, forced interwar British medicine to confront the psychological roots of illness. It may have been economically feasible to treat the neurasthenia of the Victorian middle and upper classes as a condition of the nerves, resulting in an ongoing cycle of consultations and rest cures. However, it was a different thing altogether when it came to treatment under the National Insurance and Workmen’s Compensation systems, particularly as economic depression both heightened consciousness about malingering and increased the volume of claimants.46 There was an economic incentive for employers and the state to move toward the notion that debilitating illnesses such as neurasthenia, gastric ulcers, and rheumatism were at least partly in the mind. Indeed, by the mid-1930s there was widespread publicity for the idea that a third of all sickness in Britain had psychological origins.47 Crude economics, however, was not enough to overcome ideological resistance in general, in medicine, and in politics: in general, from a prevailing rationalist perspective; in medicine, from a dominant organicist perspective; and politically, from

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those who defended the interests of the working-class claimant. Nevertheless, in a piecemeal and quiet fashion, voluntary hospitals did begin to establish psychological departments to handle those who continuously turned up for treatment without any easily definable organic basis—the “bottle of medicine” cases. These departments started to receive an increasing number of cases from general practitioners. They would arrange psychotherapy, use the services of psychiatric social workers and psychologists, and would have their own specialists or might liaise with a local mental hospital.48 Of course, the voluntary hospitals had serious economic problems of their own in the period, and specialist staff was hard to find; psychological services were even patchier outside London.49 Provision of mental treatment outside of the mental hospital may therefore have been more important than perhaps hitherto recognized, but it was far from meeting the vision of the mental hygienists of mental clinics for the general population. The final element in the emergence of outpatient care was the creation of independent clinics. This is a story of innovation making up for the inadequacy of the mental hospitals, a story of the pathbreaking use of psychotherapy, and a story of the breakdown of barriers between mental illness and health. As a tale of pioneers, it deserves attention, but we should also bear in mind its limitations of scale.50 Several key members of the National Council for Mental Hygiene were involved in setting up such pioneering clinics. Helen Boyle, whose work is examined elsewhere in this volume, is said to have been the person who first had the idea of the council following a visit to the United Sates and Canada.51 Another key figure was Maurice Craig, a founding member of the National Council, its chairman from 1928, and one of its driving forces until his death in 1935. Craig was one of the leading consultants of the era and coauthor of one of the leading textbooks on psychiatry in Britain—a traditional background in some respects, but not one shaped by serving as medical superintendent for a huge asylum. Like many others in the British context, his views were challenged and changed by the experience of shell shock in the First World War.52 Recognizing that the problems suffered by troops had their counterpart in civilian life, Craig would persuade Sir Ernest Cassel, a wealthy businessman, to support the creation of a hospital for educated people of moderate means who were suffering from functional nervous disorders.53 The Cassel Hospital, opened in 1921 with accommodation for fifty-two residents, would use a combination of rest cure and persuasion therapy, representing an extension of a fairly traditional approach to a wider clientele rather than any radical psychotherapeutic departure. By 1934, it had treated 2,270 people, and follow-up studies suggested that 45 percent were now completely well and 25 percent improved after an average stay of 4.1 months.54 No doubt, the Cassel and its like provided a much needed and valued service, but the modesty of achievement in terms of scale, in terms of social reach, and in terms of

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therapeutic innovation is characteristic of the limited nature of the victories in psychiatric reform of this era. A more radical model of psychiatric therapy was provided by what has come to be known as the Tavistock Clinic.55 The fact that its roots reach back before the First World War indicates the danger of regarding shell shock, for all its undoubted significance in the case of the clinic’s founder Hugh Crichton Miller and more generally, as the sole springboard for the reorientation in psychological medicine in the period. Recent studies have emphasized that although the British may have been frosty about some aspects of Freud, and the medical profession hostile to psychoanalysis in some notable instances, there was a huge public excitement about the “new psychology” in the first decades of the twentieth century.56 One of the things that we are beginning to recognize is that a culture of mental health care emerged from below as much as from above. The Tavistock Clinic represents one of those instances in which members of the medical profession took the reins. But even here it is worth noting that psychology also catered to some of the spiritual concerns of its founders—in its early years it would be known as the “Parson’s Clinic.”57 Elsewhere, orthodox and unorthodox religion alike, as well as a host of entrepreneurs, would take the reins.58 In the aftermath of the First World War, the medical profession would consider a move into clinical care not only because of the experience of war but also as a response to lay competition and to the profession’s concern (shared with laypersons) that medicine was overly materialist.59 The Tavistock Clinic, and Miller in particular, would be dismissed as psychiatric amateurs, even cranks, by the director of the Maudsley Clinic, Edward Mapother. Part of his dismissive attitude was due to London rivalry in the joust to attract resources; but Mapother’s contempt also reflected very different visions of the path to psychiatric modernization. Looking across the Atlantic, Alan Gregg and the Rockefeller Foundation remained firmly on the side of the Maudsley throughout the 1930s, representing as it did the best prospects for research into the biological origins of mental illness in Britain, and thus of following the lead of psychiatry in Germany and the United States. The Tavistock, by contrast, concerned itself primarily with the provision of psychotherapeutic care, which the Foundation regarded as none of its responsibility.60 But in terms of fulfilling the mental hygiene mission of radically extending the reach of mental health care, the Tavistock was a model of what might be achieved. By the 1930s, some twenty-five thousand consultations took place every year, a large proportion for the working class. Equally apparent, however, was that demand for the service was far greater than the capacity: the Tavistock operated from nine in the morning until ten at night but still faced long waiting lists.61 Because of the time-consuming nature of psychotherapy, the need for trained specialists, and the problem of having to look for endowments if such work was to be supported for those unable to pay for

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it, it proved virtually impossible to expand such services at anywhere near the same rate as the rapidly escalating perceptions of the problem. The same would be true when it came to child guidance clinics. Here again the emergence of outpatient clinics was shaped by indigenous circumstances.62 The child guidance model developed in the United States was influential, and the economic assistance of the North American Commonwealth Fund was crucial in the expansion of the British clinics. The Fund supported the London Child Guidance Clinic as a model and center of influence, supported training courses for psychiatric social work at the London School of Economics, and offered fellowships for workers in the field of psychiatry to get first-hand experience of American practice. But the British child guidance clinics did not rigorously adhere to a single model and did not depend on this external aid. In 1938, there were seventeen clinics that followed the recommended model of a medical director assisted by a team that included qualified psychologists and psychiatric social workers; twentytwo clinics went their own way. The model of using psychiatric social workers as key agents in extending the reach of mental hygiene care clashed to some extent with existing developments in clinical practice in Britain. The achievement in setting up these child guidance clinics by the end of the 1930s was impressive in terms of innovation, though less impressive in terms of reaching out to the potential child population in need as a whole.63 When it came to attempts to set up clinics to deal with the psychological casualties of industry, the political sensitivity of a mental diagnosis and the problem of resources meant that there was no hope at all.64

The Propagandist Strategy This context of limited achievements meant that British mental hygiene was to a considerable extent a movement of aspiration, education, and exhortation. With clinical provision so limited, mental hygiene endeavors focused on emphasizing the message instead; it could at least inform people about what they should be doing to remain mentally healthy, and so provided common sense advice about lifestyle and guidance about where to turn if things did go wrong. The National Council for Mental Hygiene took up the reins on getting the message out, not only by publishing articles on the mental hygiene of everyday life in its journal but also by touring the country to lecture in public halls and using the media to reach the public. By the late 1930s, virtually all the mental health organizations of the period regarded their public education and outreach activities as increasingly important. After the Second World War, it became a mainstay of the work of the National Association for Mental Health. There was irony in, and something of a problem with, this movement outward of British mental hygiene. Within the medical profession, as represented

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by the National Council, there was deep skepticism, or even outright hostility, to the idea that normal members of the public could understand the principles behind mental hygiene. It was fine to tell people how to behave, but it could be downright dangerous to encourage them to be their own psychotherapists. Indeed, the project of reaching out to the public was in part a reaction against the popularization of psychotherapeutic theory and practice that in these years took place outside the control of the profession.65 This meant it was a rather timid message: one that was aware of the danger of encouraging the public to go down the path of self-analysis, and also that spreading awareness of mental problems could actually exacerbate mental health through the resulting worry. “There is nothing more inimical to mental hygiene,” argued Doctor Henry Yellowlees, “than this utterly vicious principle of ‘every man his own psychologist,’ or rather, ‘every man his own psychological broadcaster.’ The extent to which we aid and abet the public in this game of fads, slogans, and short cuts, is a blot on our profession.”66 Thus, the mix of radical self-improvement, spiritual growth, and sheer excitement—some of it imported from across the Atlantic, and much of it blamed or associated with American fads such as the New Thought movement (that attracted the public to the popular psychological movements of the era)—was largely absent from the rather dull doses of common sense handed out by the National Council.67 Because of this, the mental hygiene message almost certainly lacked the popular purchase of the populists it so despised, with their cheap handbooks, correspondence courses, and practical psychology clubs up and down the country. Where the professional voice was more influential was when it came to targeted advice on specific issues, such as child rearing advice. For instance, psychologist Susan Isaacs used the journal of the Home and School Council to deliver a message that went beyond general platitudes (though the fact that she adopted the pseudonym of Ursula Wise highlights the tension between the professional and the popular). Her audience, however, was still relatively small and certainly not on the scale of Dr. Spock’s broader public in the postwar period.68 In general, the British tended to believe that they were less psychologically inclined than the Americans to embrace this sort of popular, positive-thought, neo-Freudian brand of mental hygiene.69 And in the 1960s, psychiatrist William Sargant would claim that the more pragmatic British route, in contrast to the ongoing American love affair with psychoanalysis, helped to account for the success in reducing rates of mental illness while those in the United States continued to rise.70

The Social Strategy There was, in sum, something of a mismatch in interwar Britain between a growing sense of the importance of mental hygiene, on the one hand,

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and the limitations and inadequacies of the strategies of eugenics, outpatient care, and propaganda, on the other. From the late 1930s through to the period of total war and postwar reconstruction (that saw Britain moving dramatically, to outside eyes at least, in a socialist direction), a final social strategy emerged as a possible solution to establishing a mental hygiene program nationwide. In addition to the inadequacies of the existing strategies, there were two further factors behind this reorientation toward mental health. One was theoretical, the other more political and ideological. The roots of both went back to the start of the period, even if their implications only fully came to the fore toward its end. The early twentieth century has rightly been characterized as an era of individual psychology; the mental test in particular, but also psychotherapy, rested on and reinforced a calculus of individual difference. However, the era saw all psychology becoming social psychology.71 The influence of anthropology played a part, as evident in the way it informed William McDougall in his influential An Introduction to Social Psychology of 1908. Social setting mattered; it changed individual action. Wholly individualist action was impossible within a social context. If psychology was the study of human nature, and mental hygiene the project of improving it, both by implication needed to look at society as well as the individuals located within it. Of course, in the first decades of the century, few were going to listen, let alone act, when someone like McDougall pushed this idea to its logical, and in his case elitist, conclusion, with his calls for psychologists to be at the heart of government.72 Confidence in the rationality of human nature faltered because of the First World War. With the rise of extreme nationalism and xenophobia and the prospect of another descent into mass slaughter in the 1930s, the need to consider and address the social roots of mental health became forcefully apparent. Throughout the interwar period, such anxieties fuelled the spread of progressive education designed to enable children to express their innate aggressiveness and to cultivate tolerance and democratic inclinations. The Second World War provided the best opportunity for a social strategy in mental hygiene; the power of the state was greater than ever and the war brought to the fore Nazism as a model of the political results of unhealthy mental development.73 Psychoanalyst Edward Glover saw the potential of the state’s new interest in recording public opinion as way to turn the democratic process itself into a tool of psychotherapy—or “social psychiatry,” as he called it.74 The theory of an interrelationship between liberal values and mental health similarly went on to shape British propaganda, the premise being that suppressing information was bad for mental health.75 As attention turned to reconstruction, there was a brief moment in which these concerns about mental hygiene became quite influential in the intellectual debates about the need for a welfare state. In this climate, mental hygienists found it much easier than before to reach the broader population. When it came to the Home Front this was

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evident, for instance, in their key role in the important process of wartime evacuation, and to a lesser extent in the mobilization of the wartime economy through its role in industry. This role was also evident in the armed forces.76 Here, but also on the Home Front, shortages of expert personnel were dealt with by group therapy: a method that had ideological appeal as a practical manifestation of the idea of the relation of democracy to mental health. Yet the ideological and practical circumstances of war that were so helpful to the extension of mental hygiene in Britain would soon pass. The war left Britain in severe economic straits. Plans for psychotherapy to be at the heart of tackling what one advocate of a radical version of mental hygiene called the “Sick Society,” or, more modestly, for an extension of mental health services to be like the new National Health Service—something for all—fell away.77

Conclusion The mid-century ideological and national crisis had undoubtedly been important in steering British mental hygiene toward an ambitious social strategy. However, fundamental problems remained. There was still a huge gap between the ambitions of a mental hygiene program and its practical achievements. The sense of wartime urgency and opportunity dimmed with the peace. There was more talk than ever about promoting mental health, but there was still nothing deserving the name of a national mental health service. Psychotherapy was still mainly the preserve of the rich.78 Promotion of mental health continued to be through a popular market of advice and self-improvement literature than through any state-imposed prescriptive or planned vision of mental hygiene. The reorientation toward mental health also did little for the system of hospitals for the mentally ill and defective.79 Here, Britain might not have followed Germany’s eugenics program, but the best that can be said is that the government largely chose to ignore a situation of ongoing neglect. Reflecting on the development of British mental hygiene as a psychiatric discipline, it is easy to conclude that the United States had a far more significant influence on Britain than did Germany. The German influence, first in eugenics, and second in the relationship between mental health and Nazism in the Second World War, was predominantly a negative one. In some respects this was also the case with regard to the United States: British mental hygiene, particularly the kind espoused by psychiatrists, tended to associate a vulgarized populist mental hygiene with the United States. This negative association undoubtedly had some truth to it: Britain provided a linguistically available market for the expansion of a host of American mental hygiene entrepreneurs. But the negative association was

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also a convenient fiction to put such popular psychology in its place, and a reflection of professional insecurities as well as a general cultural elitism that associated a burgeoning consumerism with American vulgarity. In fact, popular psychology also had strong indigenous roots.80 When it came to professional attempts to take on the banner of mental hygiene, British psychiatry, but also the new field of psychiatric social work, undoubtedly benefited from American examples, ideas, and writings, and in a few instances from direct philanthropic support and training. However, the existing pattern of law, state provision, professional development, and political will meant that there were some important distinctions between mental hygiene on the two sides of the Atlantic. Indeed, these were the forces that more fundamentally shaped British mental health or mental welfare—such terms always a more prevalent way of talking about this field than the term “mental hygiene.” In short, the story of mental hygiene in Britain points to the existence of channels for international dialogue, influence, and support, but it also highlights the potential divisiveness of national difference in this era. British mental hygiene would have been different without America (or even Germany), and it would have been called something else (indeed, it often was), but psychiatry would still have developed in the same general direction toward outpatient and preventive care: the momentum, and the distinctiveness to an American or German route, was already in place before the naming of mental hygiene; and that distinctiveness—or at least this was what the British believed by the Second World War—was arguably manifest even after and perhaps partly because of the opportunity for these channels of international influence.

Notes 1. Hans Pols, Managing the Mind: The Culture of American Mental Hygiene, 1910– 1950 (PhD diss., University of Pennsylvania, 1997). 2. Norman Dain, Clifford Beers: Advocate for the Insane (Pittsburgh: University of Pittsburgh Press, 1980). 3. Nathan Hale, Freud and the Americans: The Beginnings of Psychoanalysis in the United States, 1876–1917 (Oxford: Oxford University Press, 1971); Hale, The Rise and Crisis of Psychoanalysis in the United States (Oxford: Oxford University Press, 1995). 4. Mathew Thomson, “Mental Hygiene as an International Movement,” in International Health Organizations and Movements, 1919–1939, ed. Paul J. Weindling (Cambridge: Cambridge University Press, 1995), 283–304. 5. Vincent Brome, Ernest Jones: Freud’s Alter Ego (London: Caliban, 1982), 72. 6. Thomson, “Mental Hygiene,” 283–304. 7. Doris Odlum, “Report on Second International Congress on Mental Hygien,” Mental Hygiene (New York) 7 (1923): 882–90; Clifford Beers, A Mind that Found Itself: An Autobiography (New York: Longmans, Green and Co., 1913), 313.

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8. Report of the Feversham Committee: The Voluntary Mental Health Services (London, 1939). 9. Annual Report of the World Federation of Mental Health (London, 1949). 10. Mathew Thomson, The Problem of Mental Deficiency: Eugenics, Democracy, and Social Policy in Britain, c. 1970–1959 (Oxford: Oxford University Press, 1998), 149– 79. 11. Vicky Long, Changing Public Representations of Mental Illness in Britain, 1870– 1970 (PhD diss., University of Warwick, 2004), 178–232. 12. The background of the different groups is given in the Report of the Feversham Committee: The Voluntary Mental Health Services (London, 1939). 13. M. J. Powers, “Some Observations on Mental Hygiene Work in England,” Mental Hygiene (New York) 7 (1923): 588–94. 14. John Robert Lord, “American Psychiatry,” Journal of Mental Science 76 (1930): 461. 15. Mathew Thomson, “Constituting Citizenship: Mental Deficiency, Mental Health and Human Rights in Inter-War Britain,” in Regenerating England: Medicine and Culture in Inter-War Britain, ed. Christopher Lawrence and Anna-K. Mayer (Amsterdam: Rodopi, 2000), 231–50. 16. Richard Soloway, Demography and Degneration: Eugenics and the Declining Birthrate in Twentieth-Century Britain (Chapel Hill: University of North Carolina Press, 1990). 17. Roy Porter, “Two Cheers for Psychiatry! The Social History of Mental Disorder in Twentieth-Century Britain,” in 150 Years of British Psychiatry, Volume II: The Aftermath, ed. German Berrios and Hugh Freeman (London: Athlone, 1996), 383–406. 18. For further discussion of the relationship between medicine and mental health in the Britain of this period: Mathew Thomson, Psychological Subjects: Identity, Culture and Health in Twentieth-Century Britain (Oxford: Oxford Univeristy Press, 2006), 173–206. 19. On the influence of the United States: Mark Jackson, The Borderland of Imbecility: Medicine, Society and the Fabrication of the Feeble Mind in Late Victorian and Edwardian England (Manchester: Manchester University Press, 2000), 7, 18, 23; Thomson, Mental Deficiency, 118–9. For American developments: James W. Trent Jr., Inventing the Feeble Mind: A History of Mental Retardation in the United States (Berkeley: University of California Press, 1994); Leila Zenderland, Measuring Minds: Henry Herbert Goddard and the Origins of American Intelligence Testing (Cambridge: Cambridge University Press, 1998); Iain Dowbiggin, Keeping America Sane: Psychiatry and Eugenics in the United States and Canada, 1880–1940 (Ithaca: Cornell University Press, 1997). 20. Edward J. Larson, “The Rhetoric of Eugenics: Expert Authority and the Mental Deficiency Bill,” British Journal for the History of Science 24 (1991): 45–60. 21. Mental Hygiene 3, 4 (October 1937): 117–18. 22. Thomson, Mental Deficiency, 128. 23. Most notably in a government survey in the late 1920s that set the level at 10.49 per 1,000 persons, a doubling since the start of the century: Report of the Interdepartmental Committee on Mental Deficiency, 1925–1929 (Wood Report), 3 volumes (London: HMSO, 1929). 24. Adrian Wooldridge, Measuring the Mind: Education and Psychology in England, c. 1860–1990 (Cambridge: Cambridge University Press, 1994).

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25. A. Walk, “The Royal College of Psychiatrists,” St. Bartholomew’s Hospital Journal 77 (1973): 135–39; “Report of the Committee Regarding Status of British Psychiatry” and Discussion, Journal of Mental Science 60 (1914): 667–93. 26. John L. Crammer, “Training and Education in British Psychiatry,” in 150 Years of British Psychiatry, Volume II, 209–42. 27. Alfred Frank Tredgold, Mental Deficiency (London, 1908). 28. Jackson, Borderland of Imbecility; David Wright, Mental Disability in Victorian England: The Earlswood Asylum, 1847–1901 (Oxford: Oxford University Press, 2002). 29. Thomson, Mental Deficiency, 194–95. 30. Lionel Penrose, A Clinical and Genetic Study of 1280 Cases of Mental Defect (London: Medical Research Council, 1938); Daniel Kevles, In the Name of Eugenics: Genetics and the Uses of Human Heredity (New York: Knopf, 1985), 146–63. 31. C. Hubert Bond, “After-Care in Cases of Mental Disorder and the Desirability of its More Extended Scope,” Journal of Mental Science 59 (1913): 274–86. 32. Thomson, Mental Deficiency, 149–79. 33. Lord served as assistant editor of the Journal of Mental Science from 1900 and senior editor from 1914, and he was president of the Royal Medico-Psychological Society in 1926: Obituary, Journal of Mental Science 77 (1931). 34. John Robert Lord, Mental Hospitals and the Public (London: Adlard & Son, 1927). 35. Michael Gelder, “Adolf Meyer and his Influence on British Psychiatry,” 150 Years of British Psychiatry, 1841–1991, eds. German Berrios and Hugh Freeman (London: Gaskell, 1991). 36. John Robert Lord, “American Psychiatry,” Journal of Mental Science 76 (1930): 456–95. 37. Ibid. On community care for mental defectives: Thomson, Mental Deficiency, 149–79. 38. Lord, American Psychiatry, 486–88. 39. Patricia Allderidge, “The Foundation of the Maudsley Hospital,” 150 Years of British Psychiatry, 1841–1991, 79–88; Edgar Jones, “Aubrey Lewis, Edward Mapother and the Maudsley,” European Psychiatry on the Eve of War: Aubrey Lewis, the Maudsley Hospital, and the Rockefeller Foundation in the 1930s, ed. K. Angel et al. (London: The Wellcome Trust Centre for the History of Medicine at UCL, 2003), 3–12. 40. Thomson, Mental Deficiency, 233–34. 41. W. J. T. Kimber, “Social Values in Mental Hospital Practice,” Journal of Mental Science (January 1939): 30–31. 42. Ibid; W. J. T. Kimber in report of meeting of Royal Medio-Psychological Association, The Lancet (22 July 1939): 201. 43. Annual Report of the Board of Control for 1931, 51–52. 44. Though even in provincial North Wales, a picture emerges of a degree of progress in therapy: Pamela Michael, Care and Treatment of the Mentally Ill in North Wales, 1800–2000 (Cardiff: University of Wales Press, 2000). 45. Charles P. Blacker, Neurosis and the Mental Health Services (London, 1946), 9–10. 46. Mathew Thomson, “Neurasthenia in Britain,” in Cultures of Neurasthenia: From Beard to the First World War, ed. Marijke Gijswijt-Hofstra and Roy Porter (Amsterdam: Rodopi, 2002), 77–95.

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47. J. L. Halliday, British Medical Journal (Supplement) (9 and 16 March 1935). 48. Blacker, Neurosis, 17–19. 49. Ibid., 6–10. 50. Even here historical work has been sketchy and the most detailed studies are from practitioners; particularly useful is Henry V. Dicks, Fifty Years of the Tavistock Clinic (London: Routledge, 1970). See also Robert D. Hinshelwood, “Psychodynamic Psychiatry before World War I,” in 150 Years of British Psychiatry, 1841–1991, 197–205; Malcolm Pines, “The Development of the Psychodynamic Movement,” in 150 Years of British Psychiatry, 1841–1991, 206–31. For a recent case study: Suzanne Rait, “Early British Psychoanalysis and the Medico-Psychological Clinic,” History Workshop Journal 58 (2004): 63–85. 51. Louise Westwood, “A Quiet Revolution in Brighton: Dr. Helen Boyle’s Pioneering Approach to Mental Health Care, 1899–1939,” Social History of Medicine 14 (2001): 439–57; Dain, Beers, 211. 52. Martin Stone, “Shellshock and the Psychiatrists,” in The Anatomy of Madness, Volume II, ed. William Bynum et al. (London: Tavistock, 1985–8), 242–71; Peter Leese, Shell Shock: Traumatic Neurosis and the British Soldiers of the First World War (Basingstoke: Macmillan, 2002); Peter Barham, Forgotten Lunatics of the Great War (New Haven: Yale University Press, 2004). 53. Obituary, Mental Hygiene (January 1935): 1–5. 54. T. A. Ross, An Enquiry into Prognosis in the Neuroses (Cambridge: Cambridge University Press, 1936), 6, 78–80. 55. The Tavistock emerged out of Bowden House, a prewar nursing home for people with functional nervous diseases. In the 1930s, it was also known as the Institute of Medical Psychology. 56. Michael Clark, “The Rejection of Psychological Approaches to Mental Disorder in Late Nineteenth-Century British Psychiatry,” in Madhouses, Mad-doctors, and Madmen, ed. Andrew Scull (Philadelphia: University of Pennsylvania Press, 1981), 271–312; Trevor Turner, “James Crichton-Browne and the Anti-Psychoanalysts,” in 150 Years of British Psychiatry, Volume II, 144–55; Graham Richards, “Popularizing Psychoanalysis: Britain 1918–1940,” Science in Context 13 (2000): 183–230; Dean Rapp, “The Early Discovery of Freud by the British General Educated Public, 1912–1919,” Social History of Medicine 3 (1990): 217–43. 57. Ruth Rouse and Hugh Crichton Miller, Christian Experiences and Psychological Processes (London, 1917). 58. Graham Richards, “Psychology and the Churches in Britain, 1919–1939: Symptoms of Conversion,” History of the Human Sciences 13 (2000): 57–84. 59. Christopher Lawrence, “Still Incommunicable: Clinical Holists and Medical Knowledge in Interwar Britain,” in Greater Than Their Parts: Holism in Biomedicine, 1920–1950, eds. Christopher Lawrence and George Weisz (Oxford: Oxford University Press, 1998), 94–111. 60. Rockefeller Archive Center, Sleepy Hollow, New York (hereafter RAC), folders 336–40, box 26, series 401, Record Group (hereafter RG) 1.1. 61. “Neurotic Disorder and Industrial Efficiency,” RAC, folder 339, box 26, series 339, RG 1.1. 62. For instance: John Stewart, “Child Guidance in Inter-War Scotland: International Context and Domestic Concern,” Bulletin of the History of Medicine 80 (2006): 513–39.

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63. Deborah Thom, “Wishes, Anxieties, Play, and Gestures: Child Guidance in Interwar Britain,” in In the Name of the Child, ed. Roger Cooter (London: Routledge, 1992), 200–19. 64. MSS 292/140.1/2, Trades Union Council Archive, Modern Records Centre, University of Warwick. 65. Mathew Thomson, “The Popular, the Practical and the Professional: Psychological Identities in Britain, 1901–1950,” in Psychology in Britain: Historical Essays and Personal Reflections, ed. Geoffrey C. Bunn et al. (London: British Psychological Society, 2001), 115–32. 66. Henry Yellowlees, “Mental Hygiene in Modern Life,” in Out of Working Hours: Medical Psychology on Special Occasions (London: Churchill, 1943), 77. 67. On this popular excitement: Mathew Thomson, “Psychology and the ´Consciousness of Modernity’ in Early Twentieth-Century Britain,” in Meanings of Modernity: Britain from the Late-Victorian Era to World War II, ed. Martin Daunton and Bernhard Rieger (Oxford: Berg, 2001), 97–115. 68. Catherine Urwin and Elaine Sharland, “From Bodies to Minds in Childcare Literature: Advice to Parents in Inter-War Britain,” in In the Name of the Child, ed. Roger Cooter (London: Routledge 1992), 174–99; Christina Hardyment, Dream Babies: Child Care from Locke to Spock (London: Jonathan Cape, 1983). 69. For instance: Geoffrey Gorer, The Americans: A Study in National Character (New York: W. W. Norton & Co., 1948), 50. 70. “U.S. Psychiatry Isolated from the World,” The Times, 25 August 1964. 71. Nicholas Rose, The Psychological Complex: Psychology, Politics and Society in England, 1869–1939 (London: Routledge, 1985). 72. Reba Soffer, “The New Elitism: Social Psychology in Prewar England,” Journal of British Studies 8 (1989): 111–40. 73. Mathew Thomson, “Before Anti-Psychiatry: Mental Health in Wartime Britain,” in Cultures of Psychiatry and Mental Health Care in Postwar Britain and the Netherlands, ed. Marijke Gijswijt-Hofstra and Roy Porter (Amsterdam: Rodopi, 1998), 43–59. 74. Edward Glover, “The Birth of Social Psychiatry,” The Lancet (24 Aug. 1940): 239. 75. Michael Balfour, Propaganda in War, 1939–45: Organisation, Policies and Publics in Britain and Germany (London: Routledge, 1979); Ian McLaine, Ministry of Morale: Home Front Morale and the Ministry of Information in World War II (London: Allen & Unwin, 1979). 76. Ben Shephard, A War of Nerves: Soldiers and Psychiatrists, 1914–1994 (Cambridge: Harvard University Press, 2001), 325–38. 77. James L. Halliday, Psychosocial Medicine: A Study of the Sick Society (London: Heinemann, 1948); Blacker, Neurosis. 78. Michael Balint, The Doctor, the Patient and the Illness, 2nd ed. (London, 1964), 282. 79. Thomson, Mental Deficiency, 270–96. 80. Thomson, Psychological Subjects, 17–53.

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Chapter Eight

Psychiatry in Munich and Yale, ca. 1920–1935 Mutual Perceptions and Relations, and the Case of Eugen Kahn (1887–1973) Volker Roelcke During the period between ca. 1900 and the mid-1930s, German academic psychiatry was to some degree perceived as a model for clinical practice, research, and institutional organization in the field.1 However, parallel to the interest of British, American, and other psychiatrists in German psychiatry, there emerged among German psychiatrists themselves a growing multifaceted discontent about academic medicine in general and about aspects of the dominant approach in psychiatry in particular. Already during the 1920s, this discontent led some psychiatrists such as Eilhard von Domarus and Eugen Kahn to look to other academic cultures, in particular to that of the United States, which appeared to be characterized by a more open academic life, better career opportunities, and chances to develop new approaches to mental health care.2 The career of Eugen Kahn in Munich and at Yale is an exemplary case study of the mutual perceptions and evaluations of American and German psychiatrists in the late 1920s and early 1930s. It provides insights into the consequences of such mutual images on the decisions and activities of individual psychiatrists as well as of institutions such as universities or the Rockefeller Foundation. Kahn’s move from the prestigious Psychiatric Clinic in Munich to the first chair of the Department of Psychiatry and Mental Hygiene at Yale in 1930 also provides some insight into the question of what might happen if such mutual perceptions conceived from a distance were put to the test: The Yale medical faculty, as well as Kahn himself, had opportunites to check on their previous expectations in everyday academic life. As the case shows, the high expectations did not stand up to reality, and Kahn was urged to resign in

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1946. The mutual disappointment may have been due in part to personal factors, but it also illustrates important features of contemporary American and German psychiatry, and of academic life more generally. This chapter first summarizes the moves to establish a department of psychiatry at Yale in the 1920s and the expectations of the relevant individuals and institutions responsible for the appointment of Kahn. Second, it gives a short outline of the Munich school, and Kahn’s specific achievements and interests around the time of his decision to move across the Atlantic in 1929/30. Third, it analyses the conflicts and developments concerning academic psychiatry at Yale in the early 1930s that led to Kahn’s early resignation as chair in 1946.

The Program of Psychiatry and Mental Hygiene at Yale in the Late 1920s In November 1929, the American Journal of Psychiatry announced the appointment of Dr. Eugen Kahn, of Munich, as professor of psychiatry and mental hygiene at the Yale School of Medicine. The announcement stated: The Rockefeller Foundation has pledged 100,000 Dollars a year for ten years toward a program to develop the study of psychiatry and mental hygiene at Yale. Dr. Kahn’s appointment is among the first in connection with this program. The foundation also is providing funds for the Institute of Human Relations building. . . . Dr. Kahn for years worked with the late Dr. Emil Kraepelin. When Dr. Kraepelin decided, in 1925, to give his whole time to the German Psychiatric Research Institute in Munich, which he had founded, he left the active direction of the psychiatric and nerve clinic at the University of Munich to Dr. Kahn, who has since been professor there. . . . The keynote [of Dr. Kahn’s future work in Yale] is to be the prevention of mental disease by tracing it to the contributing factors and origins.3

This note gives some indication of the contexts and expectations of Kahn’s appointment: the prevention of mental disease and research into its origins were to be the focus of the newly created department and its chair. These expectations were shared by the dean of the medical school, Charles Winternitz, and the president of Yale, the psychologist James Rowland Angell, as well as by the Rockefeller and the Carnegie Foundations, the philanthropic institutions providing the funds for the new program. The expectations may be understood as the specific expression and result of two major agendas in the realm of academic medicine and mental health care: the mental hygiene movement so prominent in American society during the first decades of the century, and the reform of medical education and research at Yale.

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The Mental Hygiene Movement in the 1920s and Its Impact on Institutional Psychiatry In the interwar period, the public awareness and image of mental disorder, as well as mental health policies, were to a considerable degree shaped by the mental hygiene movement.4 Founded in 1911 by businessman and former psychiatric patient Clifford Beers (1876–1943) and Adolf Meyer (1866– 1950), professor of psychiatry and chair at Johns Hopkins University, the central mission of the National Committee of Mental Hygiene (NCMH) was to develop measures that would prevent behavioral maladjustment and mental illness. To achieve this goal, the National Committee vigorously encouraged the expansion of the scope of psychiatry beyond the walls of the mental hospital. The NCMH’s leaders considered the popularization of psychiatric insight to be one of its central tasks; they propagated the view that psychiatry was not only about mental illness in the narrow sense, but that it could also provide the scientific foundations for life in the modern world. This fundamental premise implied a shift in the focus of psychiatry from institutional care to the community. Such ideas and goals were closely associated with Adolf Meyer’s concept of mental disorder. Meyer advocated the view that the core feature of mental illness was a behavior disorganization. He considered this disorganization to be the outcome of an individual’s inability to adjust to social demands and standards. This sociobehavioral approach expanded the range of psychiatry to include all kinds of difficulties in conduct. It also implied a perspective for intervention based on environmental or behavioral modification. As one consequence of this perspective, Meyer developed an elaborate reform agenda to complement the traditional psychiatric services, in particular through a program of after-care outpatient clinics and social services at mental hospitals. Meyer also advocated the view that crime and dependency had their causes in the inability to adjust to current social norms and were therefore problems of maladjustment. As a consequence of Meyer’s and the National Committee’s initiatives, in 1916 the Rockefeller Foundation approved a grant for the psychiatric study of inmates of jails and correctional institutions in New York State. The results indicated that about 60 percent of the prison population suffered from one or another mental disorder. The study also suggested that the goals of preventing criminality and of bringing the inmates back into the community could not be achieved without psychiatric expertise. Thomas W. Salmon, who had become the first medical director of the National Committee in 1912, propagated the view that the “prevention of insanity [is] only a phase of the general warfare against preventable diseases.” Psychiatry should therefore be considered part of the public health movement. One of the consequences was that it had to use the statistical and epidemiological methodology of public health research developed

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to study the spread of contagious diseases. Following Meyer’s initiative in New York, Salmon therefore propagated the introduction of standardized recordkeeping and statistics nationwide. For this purpose, in 1917 the American Medico-Psychological Association adopted a diagnostic system based on Emil Kraepelin’s psychiatric classification in order to facilitate statistical surveys and recommended the adoption of this system by all mental hospitals. The systematic collection of epidemiological data in the German states had already been a central goal for the formulation and acceptance of Kraepelin’s terminology and classification there.5 A bureau of statistics at the NCMH was established, funded by the Rockefeller Foundation. Using mental hygiene surveys on the general population, psychiatrists demonstrated that individuals very much like those institutionalized in mental hospitals were present in the wider society, posing both a menacing threat to the social order and a huge challenge for an expanded field of psychiatry and mental health care. The implication was that mentally ill individuals were responsible for a wide variety of social problems that could be prevented if proper programs for prevention and care were available. These features of the American mental health movement had a considerable impact on the specific constellation of factors leading to the establishment of a department of psychiatry and mental hygiene at Yale in the late 1920s. The second development that contributed to this situation was the cooperative initiative of a group of leading Yale figures to reform the structure of teaching and research in academic medicine, together with the institutionalization of the social sciences.

Medicine as a Social Science: Reform Agendas at Yale in the 1920s In the years following the First World War, a number of initiatives converged to contribute to the institutionalization of the social sciences in the United States. The National Research Council, established in 1916, supported a program of interdisciplinary studies that included an approach to medicine as a social science. Already at the turn of the century, the University of Chicago had perpetuated and reinforced the Enlightenment belief in the social sciences as vehicles for promoting social, economic, and political reform. This approach advocated the view that universities and academics should contribute to a better understanding of society and help resolve problems such as waste, inefficiency, and societal and personal maladjustment.6 This broader agenda shaped an awareness of the shortcomings of academic medicine, which, as a consequence, led to a program at Yale University to reform it as a social science. The main actors of this reform agenda were James Angell, psychologist, and from 1921 president of Yale University, and Charles Winternitz, anatomist, and dean of the Yale Medical School

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from 1920 until 1935.7 Angell had attended some of the most prestigious academic institutions in the United States and Europe. He had been a student or colleague of John Dewey, Wilhelm Wundt, Hermann Ebbinghaus, and Friedrich Paulsen. He had served as professor and chair in psychology, and in addition as dean and provost at the University of Chicago, as chair of the National Research Council, and as president of the Carnegie Corporation. Winternitz had received his medical training at Johns Hopkins University and Medical School as a disciple of the distinguished William Henry Welch.8 Both Angell and Winternitz believed that a new synthesis between the social sciences and medicine would force the university to extend its resources to consider community and societal problems of a practical nature. They suggested that it was the responsibility of the university to break down barriers between departments, programs, and schools, and provide the human engineering necessary for the organization of social harmony. Angell in particular fostered the idea of collaborative research beyond disciplinary boundaries. He was attracted to Winternitz’s idea that medicine was a social science.9 Both Winternitz and Angell advocated the idea that physicians and medical students should be concerned not only with sickness but also with health, not only with diseased organs but also with the whole individual; medicine should encompass not only the biological, but also man’s entire social and economic environment.10 Their ideas and activities converged in the so-called Human Welfare Group, which, in its final, institutionalized form, consisted of the schools of medicine and nursing, the New Haven Hospital, the New Haven Dispensary, and the Institute of Human Relations, a new interdisciplinary center for research between the fields of medicine, law, and the social sciences. The main question addressed by the protagonists of this program of human engineering was: How can society deal with the problems of its own organization so that the proportion of human happiness and accomplishment may be improved, the proportion of human suffering and failure be lowered? The idea to complement the traditional medical focus on the individual with a focus on the social environment, to consider both the biological and the sociological aspects of life, was not new: Charles E. A. Winslow, Lewellys Baker, and others had expressed similar ideas in the preceding years and even decades. And David Edsell in Boston, as well as George Canby Robinson in Baltimore, had even tried to put such ideas into practice within medical institutions.11 But their programs had been aimed at an internal restructuring of medical institutions, whereas that of Winternitz and Angell reached far beyond by attempting to integrate all sciences that had as their subject the human being, from biology, psychology, and the social sciences to law and even divinity.12 Perhaps even more important, they had found enormous resonance to their ideas for radical reform in academic committees and private philanthropic foundations.

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Winternitz believed that this reform program was dependent on the existence of a new department of psychiatry. Already in his 1921 dean’s report of the past academic year, Winternitz had propagated the role of psychiatry “as a major division in medical school organization.”13 Psychiatry, as he explained in a letter to Abraham Flexner in 1927, deals with the behaviour and conduct of the individual. The psychiatrist regards the individual as a whole; underlying structural [i.e., somatic] changes associated with behaviour and conduct characteristics are subsidiary. Psychiatry and psychology are approached by the study of individuals, including man and higher animals, as well as by the study of the evolution of individuals of different species. . . . Mental hygiene has as its objective improvement in the psychic well-being of the individual, and through the individual, of the group and the community.14

In an extensive “Memorandum Concerning the Establishment of an Institute of Human Behaviour at Yale University” of 1926, he outlined the importance of psychiatric knowledge for “the physician of today,” and asked for a central place for psychiatry and mental hygiene in medical research, clinical practice, and education.15 However, there existed no psychiatry department at Yale in the early 1920s.16 According to Winternitz’s plans, such an institution would represent not so much an end in itself, but rather a step toward the realization of his larger goal of a new and integrated “megafield” of pathology, physiology, psychology, divinity, and social sciences. Thus, it would be not just a new department or discipline, but a completely new approach to medicine.17 The Yale program of a reformed medical curriculum, which considered medicine as a social science, had at its core the idea that the medical student should learn to consider actual problems of human conduct, such as crime and unemployment, from legal, social, scientific, and biological points of view. The medical student should work in cooperation with students of biology, law, religion, economics, and psychology. The University Health Service would serve as a laboratory for psychological, sociological, and economic studies of patients conducted by students and experts in medicine and sociology. The expectation was that light would be shed upon societal problems, for example on the connections between physical health and family income, mental stability and occupation, child training and mental growth, etc. The Dean outlined this program in his extensive Memorandum of 1926.18 Further developments in reform at Yale proceeded in a two-track manner. On a general level the activities were targeted toward the establishment of the Institute of Human Relations; another track had the more immediate aim of establishing a department of psychiatry as the crystallization core of the later Institute. In 1925, Arthur Ruggles, superintendent of the Butler Hospital in Providence, Rhode Island, was invited to Yale for the following

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academic year to become the Yale medical school’s first visiting professor of psychiatry. The priorities set by Winternitz for the next few years were: first, to develop a program of mental hygiene for the undergraduate student body in the department of university health; second, to direct consultations in psychiatry for patients at the New Haven Hospital; third, to train medical students; and forth, to create a long-range plan for a broader program in psychiatry and mental health.19 Winternitz’s absolute priority was to institute a mental hygiene program for Yale students; this is illustrated by the fact that Ruggles was originally supposed to receive his salary from the department of university health, not from the medical school. Parallel to the temporary appointment of Ruggles, Winternitz approached the Commonwealth Fund of New York and secured a five-year grant for the establishment of the new department. Having succeeded, Winternitz began the search for the new chair. The first offer was extended to Ruggles himself, who, however, shocked Winternitz and his advisory committee when he refused the position. Ruggles argued that he felt himself not equipped to meet the ambitious expectations linked to the new position.20 Similar reactions came from Stanley Cobb, of Harvard Medical School, and from Edward Strecker of Philadelphia.21 Apparently the department and its program were too new, and future success too unpredictable, for any psychiatrist of rank to risk his reputation. As a consequence, Winternitz desisted from making yet another senior-position offer for the time being, and instead concentrated on hiring junior faculty. Two clinical assistant professors, two lecturers, and one instructor were appointed, and a psychiatric lecture series with invited speakers was inaugurated. Thus, in these years between 1926 and 1930, the department had a budget and junior staff, but no clinical base and no true headquarters.22 Also, the ambitious institutional context—the proposed Institute of Human Relations—was only about to be established, the plans emerging from the Human Welfare Group. For this purpose, Winternitz and Angell installed an advisory committee, chaired by William Welch, and composed of prominent scientists and public leaders such as Harvey Cushing, Clifford Beers, Franz Boas, William Mayo, and other notables.23 An intensive fundraising campaign was successful due to the generous contribution of $2.5 million by the Rockefeller Foundation, and a sum total of gifts amounting to $7.5 million.24 From 1929 onward, a new building was erected that would bring all the relevant disciplines under one roof and that would also house the wards of the psychiatric inpatient clinic. This was the situation in 1929 when Winternitz once again began to search for a suitable person to fill the position of chair of the new department. Lloyd Thompson, now one of the assistant professors, was sent to Europe to study psychiatric programs there. During an extended stay in Munich, Thompson met Eugen Kahn, chief of staff of the Munich Psychiatric Clinic

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under Kraepelin’s successor Oswald Bumke. In addition, Winternitz had received extensive information on the Munich psychiatrists by one of his research assistants in the Yale Department of Anatomy, Harry Zimmermann, who, during his year as visiting scholar at Walter Spielmeyer’s department of neuroanatomy at the German Research Institute for Psychiatry in Munich, had sent Winternitz information on the University of Munich clinic and department of psychiatry. Zimmermann himself later became a renowned neuropathologist and founder of the Albert Einstein Medical College in New York.

Eugen Kahn and the Munich School of Psychiatry Kahn, the son of a Jewish businessman in Stuttgart, southern Germany, was born in 1887.25 After graduating from the medical school of the University of Munich, he completed a thesis in experimental physiology in 1911. In the following year, he joined the staff of the Munich Department of Psychiatry where Emil Kraepelin, the dominating figure of contemporary German psychiatry, had been chair since 1903. During World War I, Kahn served as a psychiatrist in the army. After the end of the war and the suppression of the short-lived Communist Republic in Munich, he joined his teacher Kraepelin as an expert witness in the trials against members of the former government. Both were generous in ascribing psychiatric labels to the communist politicians, in particular in diagnosing them as hysteric personalities or psychopaths.26 Also during the 1920s, Kahn was active as an expert witness in forensic psychiatry and published on his experiences in this field.27 From 1921 onwards, Kahn was one of Kraepelin’s deputies in the Psychiatric Clinic. When in 1922 Kraepelin retired as chair, a long period of quarrels and intrigues for the succession followed. Finally, one and a half years later, against Kraepelin’s explicit intentions, Oswald Bumke, formerly at Leipzig, became the new professor. During the interim period, Kahn acted as temporary director of the clinic and the department. Under Bumke, Kahn served as chief of staff until 1929, when he received the invitation from Yale. During his Munich years, Kahn had absorbed not only Kraepelin’s ideas about nosology and classification but also his teacher’s approach to therapy and prevention. These ideas and approaches were of considerable relevance for Kahn’s own research and his activities at Yale, and are therefore outlined in the following: Kraepelin had since the early 1880s reformulated psychiatric theory and disease categories. This reformulation was first sketched in his Compendium der Psychiatrie (1883), the first edition of the later Lehrbuch (textbook) that became the standard reference work of German-language psychiatrists

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during the first half of the twentieth century. It was based on and oriented toward the methods and presuppositions of the laboratory sciences, and it promised psychiatry the prestige and the access to the same resources as these flourishing disciplines. From the outset, Kraepelin had declared that his central aim was to create a nosology that would provide a basis for successful prognosis, therapy, and prevention. Using the experimental design of contemporary experimental psychology, and the principle idea of bacteriology (i.e., monocausality), he concluded that psychiatry could develop an equally powerful approach only if clinical features were sorted out and grouped together in such a way that a common underlying cause could be assumed. This supposed underlying cause was to be the organizing principle of nosology; and it should be accessible to manipulation in a way similar to the germs identified by Louis Pasteur and Robert Koch.28 It was only in the later editions of Kraepelin’s Lehrbuch that the postulated disease entities that had been “identified” through empirical research conformed to the preempirically outlined categorical boundaries. These categories were the result of a selective research strategy that was directed toward the assumed disease entities. As a matter of fact, Kraepelin’s early theoretical reorientation toward the laboratory sciences shaped not only his further conceptualizations but also the structure of institutionalized discourse and practice in his department. For example, when Kraepelin had taken over the chair of psychiatry in Munich in 1903, he organized regular internal discussions and public seminars on a number of topics, which he enumerated in his autobiographical notes: histopathology, questions of heredity and degeneration, metabolism, and serology.29 As a result of this theoretical reorientation and the ensuing research strategy, the psychiatric tradition inaugurated by Kraepelin was dominated by a somatic-biological perspective, whereas the biographical-psychological and the sociocultural dimensions were marginalized. Psychopathological phenomena were conceived to be the expression of discrete nosological entities, with specific somatic causes, clinical features, and pathological anatomy. The categories and concepts emerging from this reconceptualization, such as the dichotomy between dementia praecox and manic-depressive insanity, had an apparent coherence and an immediate plausibility for contemporary psychiatrists. At the same time, Kraepelin also contributed to the restructuring of psychiatric institutions following the needs of quantitative empirical research, and to the reshaping of the discipline’s public image fitting to the expectations of Wilhelmine society and state authorities.30 Kraepelin’s approach also implied the view of biological deficiency as the core feature of mental disorders. Therapeutic interventions had as their target mainly the symptoms of the disorder, both those distressing for the patient and those that posed any danger to the patient’s immediate surroundings or to the public order. Being a very conservative bourgeois with

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strong patriotic and even nationalist tendencies, Kraepelin considered it one of the foremost tasks of the psychiatrist to serve the state and the nation.31 In this perspective, preventive action against the potential spread of mental disorders in the community was an important goal. The key to success was an intervention in the supposed causation of the disorders. Here, Kraepelin had identified three main factors: alcohol, syphilis, and heredity. In the years after the turn of the century, he not only fought fervently against alcohol, promiscuity, and prostitution, but also formulated a far-reaching program for an all-embracing inventory of the hereditary condition of the whole German population. This public task, as he saw it, was to be complemented by large-scale epidemiological and genetic research that would yield results for future eugenic measures.32 Repeatedly, he requested political support for this project, and in the long term he was successful. As a consequence of Kraepelin’s agenda, one of his pupils, Ernst Rüdin, launched an extensive program of empirical epidemiological and genetic research to establish the hereditary causes of dementia praecox, or schizophrenia. Rüdin’s research resulted in a monograph published in 1916, which in the following decades became a paradigm for further research in psychiatric genetics.33 In 1917, he became head of the department of genealogy and demography of the newly established German Research Institute of Psychiatry directed by Kraepelin.34 Following Kraepelin’s preferences and approach, Kahn’s work in the 1920s focused on two themes: the genetics of patients suffering from schizophrenia, and the concept of psychopathic personalities, which he and others at the time understood as the borderland between normal and psychotic individuals. In 1923 he published the results of a major genetic study as a monograph in the series on the “Heredity and Causation of Mental Disorders” edited by Rüdin.35 In this study, Kahn analyzed the genealogy of a number of families in which cases of dementia praecox had occurred.36 Kahn’s conclusions accepted and confirmed Kraepelin’s and Rüdin’s presupposition of dementia praecox as a distinct biological entity with a specific genetic causation. These results implied further support for moves to implement eugenic policies, and a rather pessimistic outlook on any potential treatment of patients with these conditions. Kahn’s concept of psychopathic personalities was similarly grounded in the presupposition that a genetic factor was the main cause of psychopathological conditions. He conceded, however, that there were a number of further aspects on top of these biological foundations. He used various psychological theories of personality and differentiated three layers of the character, which he conceived as causally linked to one another. In the late 1920s, he further elaborated this conceptualization and acknowledged the usefulness of some of the ideas advanced by Freud, Jung, and Alfred Adler.37

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With his publications on these and other topics, and his broad clinical experience in one of Germany’s most renowned departments of psychiatry, Kahn belonged to the leading figures in the discipline at the end of the 1920s. Why, then, did he leave Germany, and what were the expectations of the Yale officials toward the newcomer from Munich? Kahn’s motivations are difficult to reconstruct, since only indirect archival evidence is available. The main aspect of his decision is most likely linked to his restricted career opportunities in contemporary Germany. Being of Jewish origin, it was at the time very difficult, or almost impossible, to become appointed to the chair of a university department, particularly in medical schools. After World War I, in the context of repeated political and economic crises, radical anti-Semitism had become a constitutive force in German political and cultural life, and not less so in academic surroundings. Kraepelin himself had strong anti-Semitic and racialist sentiments, which are documented in his recently edited personal testimonial, and in some of the poems he wrote for private and semipublic occasions.38 There is also evidence that Kraepelin, however appreciative of Kahn’s achievement, was at least hesitant in supporting his habilitation, the formal precondition for any appointment as professor at a German university.39 Bumke appreciated Kahn’s competence but, when he succeeded Kraepelin as director of the department, he brought his own pupil August Bostroem with him from Leipzig to become his first deputy. Thus, from 1924 onwards, Kahn had the position of second deputy to the director, whereas in the one-and-a-half-year interim period between Kraepelin and Bumke, he had been the de facto director of the department and the clinic. Kahn was aware of the political and racialist preoccupations of German academia and of Kraepelin in particular. He was himself a politically conservative person, and not a critic of the dominant values of his environment. Well educated in the humanist tradition, he was a “generalist” like many of his non-Jewish academic colleagues and his cultural preferences were similar to theirs. His ambition—in terms of academic and social life—was to transcend the rather marginal status imposed on Jewish individuals and to join in with the German intellectual elite of his time. But joining in was also difficult for reasons beyond anti-Semitism. Born amid the impact of military defeat, breakdown of the monarchy, and leftwing revolution, the Weimar Republic was beset by political, social, and economic crises that made it an especially weak and fragile political entity. From the beginning, the economic outlook was precarious for German doctors in this period. Sharing the generic difficulties of readjusting to post–World War I society common to all veterans, German physicians were confronted with professional overcrowding, insufficient public resources, and intergenerational battle between younger and older colleagues scrambling for those patients who might be able to pay private dues. Within

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academia, competition was strong and hierarchies rigid. Whereas the full professors could reign over their departments in an autocratic manner, all those below had to follow orders. This more general context of Kahn’s situation in the cul-de-sac one step below the full professorship had its impact on his discontent with his position.40 A further factor in Kahn’s dissatisfaction was his slowly emerging doubt about the adequacy of the Kraepelinian perspective on mental disorder. His writings in the late 1920s indicate an increasing acknowledgment of the reductionism of his teacher’s approach and a gradual turn to more psychological, and even psychodynamic, ideas.41 It was in this context, in early 1929, that Lloyd Thompson met Kahn in Munich. After his and Zimmermann’s positive reports, Winternitz decided to travel to Germany to arrange a personal meeting with Kahn. As a result of this first encounter, he invited Kahn to spend a month at Yale.42 Kahn accepted, and in the summer of that year presented papers at Yale on the diagnosis of psychopathic personalities and on the dialogue between psychiatrists and theologians. In September, Winternitz reported to Angell: As you know, Professor Kahn has been in New Haven for a period of several weeks and during this time he has had an opportunity of acquainting himself with the general plans for the development of psychiatry and mental hygiene in association with the School of Medicine and the Institute of Human Relations. He has now had the opportunity of meeting and conferring with the majority of the members of our Board of Permanent Officers as well as with several of the professors in the departments other than those of the School of Medicine which will be associated in the work of the Institute. As far as I am able to determine, his impressions of them and their impressions of him have been mutually satisfactory. . . . I find that he is quite enthusiastic over the possibilities of the development43

In the beginning of October 1929, both the Board of Permanent Officers of the School of Medicine, and the Executive Committee of the Institute of Human Relations voted to nominate Kahn as Professor of Psychiatry and Mental Hygiene.44

Kahn at Yale: Conflicts and Consequences The immediate expectations of Winternitz and Angell toward the new professor of psychiatry and mental hygiene were threefold: first, he should be a manager able to integrate the various activities and programs of the department; second, he should initiate research in the causes of mental disorders; and third, he should be prepared to take a leading part in the interdisciplinary activities of the Institute of Human Relations.

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Kahn had proven his abilities both as researcher and as a manager of a large clinic in Munich in the interim period between Kraepelin and Bumke. Through his work on psychopathic personalities, that is, personalities on the borderline between the normal and the abnormal, and through his practical experience in forensic psychiatry, he appeared to share common ground with social scientists and lawyers. The interest of the American psychiatric community in his work is documented by the fact that his 250-page Psychopathic Personalities in Bumke’s monumental Handbuch der Geisteskrankheiten (1928) was published in an English translation by Yale University Press within one year of Kahn’s arrival.45 In addition to his supposed expertise on psychopathic personalities, he was also familiar with standardized methods of recordkeeping and statistics, which were essential for the epidemiological side of the mental hygiene movement. Finally, the notion of prevention, which at first glance appeared to gear very well to the program of mental hygiene, was a continuous thread through most of his writings. He had developed the idea in his contributions for the first German handbook on mental hygiene, where he also acted as coeditor;46 but prevention was also an underlying and explicit motivation for his extensive research on the genetics of mental disorders. The notion of prevention that may be reconstructed from his published work refers in the first instance to state policies and intervention, including deliberations on, but no explicit propagation of eugenic measures initiated and sanctioned by state authorities. In contrast, the American mental hygiene movement was primarily built on ideas of guidance and education; the consideration of eugenic measures became an issue only in the late 1920s.47 What do we know about the fulfilment of the Yale officials’ expectations? First, both published and unpublished documents give evidence that Kahn was quite successful in organizing and integrating the various activities of the department. After the opening of the Institute’s new building in the spring of 1931, the department was centralized and the new clinic established. In a short outline for the journal Medical Education, published by the Rockefeller Foundation, Kahn described the various activities of the Institute in that same year:48 The new clinic had fifty-one beds, thirty-nine of which were in single rooms; further, it had six living rooms, ample veranda space, and a large terrace for the social activities of the patients. Rooms were also provided for hydrotherapy, occupational therapy, and physical therapy. In addition to the professor, the staff of the clinic consisted of two associate professors, two residents, and three interns. The nursing staff was composed entirely of graduate nurses with some previous training in psychiatric nursing. Consultation service in all branches of medicine was available in cooperation with other departments of the medical school and New Haven Hospital.49 On the same premises, a biochemistry laboratory had been established, psychology research facilities were being developed, and—as Kahn

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stressed—space was available for future developments in genealogical and sociological approaches to the study of behavior. This setup for the various research approaches is reminiscent of the program of the German Psychiatric Research Institute, with its departments of genealogy, neuropathology, biochemistry, and experimental psychology. Notably, however, the envisaged room for “sociological approaches” was a distinct feature only at Yale and had no counterpart in the Munich Institute. It may be significant for the developments that followed that documentary evidence does not exist for any realization of such sociological research activities during Kahn’s years as head of the department. Kahn himself must have felt the competing, and in some ways contradictory, approaches of German and American psychiatric culture toward the understanding and handling of mental disorder. In a presentation at the First International Congress on Mental Hygiene in Washington, DC, held in May 1930, a few months after his arrival at Yale, he addressed what he viewed as “modern problems in psychiatry”: He talked about the conflict of a “natural science” approach, and of a “mental science” approach to psychiatric conditions. He exemplified these two approaches by the work of Kraepelin and Freud. His argument is summarized in his own formulation: “We use Kraepelin’s life-work, and we make use of whatever in Freud’s work seems to us unassailable.”50 He also acknowledged Meyer’s idea of a down-to-earth, empirical approach to the individual patient. However, this programmatic speech advocating a unified perspective seems to have met with considerable difficulties in practice. An impression of these difficulties may be gained by looking at Kahn’s publications during the next few years that reflect his research interests and his evaluations of the field. A number of papers illustrate his cautious and probing way of dealing with psychoanalytic ideas, such as the articles on the notion of “conflict” in the development of schizophrenic states, or on Alfred Adler’s concept of the “craving for superiority.”51 Further, a whole series of publications shows a very specific occupation with core concepts of Meyerian and mental hygiene assumptions. These papers have titles like “The Potentiality for Change in Personality,” or “Adjustment and Its Limits.”52 Here, Kahn attempted to develop his previous concept regarding the various strata of the personality. Now, he differentiated five aspects of a personality’s makeup: corporality, impulse life, temperament, character, and intelligence. In particular, he conceptualized the last two strata as being considerably influenced by environmental factors. He concluded: “It is character toward which we must chiefly direct therapeutic endeavour, which is always of the nature of environmental stimuli.” However, he immediately added that “even if environmental factors . . . change the individual’s behavior, it is illogical to conclude that therewith the individual is changed.”53 Thus, although he struggled to integrate the social dimension into his theoretical concepts, his presuppositions constantly referred him to the limits

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of such attempts. Another feature of these writings was the strong tendency to systematization of theoretical concepts and the classification of observable abnormal behavior, and a lack of focus on specific individual patients’ personal experience—again a tendency central to the Kraepelinian approach. In a letter to Kahn of August 1931, Adolf Meyer summarized some of the core differences between his own multidimensional, “psychobiological” views and Kahn’s classificatory psychopathological approach imbued by the Kraepelinian tradition. Meyer wrote: We have, I suppose, been more concerned with certain non-parallelistic fundamentals, because of our urge to do justice to an assimilation of psychology in a biological setting; and we have not cultivated that rigid bookkeeping and scrutiny which leads to the meticulous proprietary accounting . . . , which no doubt adds much to clearness in the genealogy of ideas, cultivated by the German writings. . . . A lack of inter-penetration is easily intelligible, considering the elaboration of the German developments.54

On the institutional level, Kahn’s time at Yale may be subdivided into two periods: the time until 1935, when a major reevaluation of the Institute of Human Relations was carried through; and the consecutive period, which was characterized by an increasing divergence of the activities of the Institute and the department. During the first period, Kahn succeeded in consolidating the clinical activities, both on the inpatient and outpatient level, and in view of the preventive counselling of the student body.55 What he did not accomplish was cooperative research with the other disciplines represented in the Institute. On the contrary, he was afraid that psychologists and sociologists might start to claim competence not only in the realm of normal behavior and prevention, but also in matters of pathological conditions. In retrospect, in a lecture held in the early 1960s at Baylor Medical School in Houston, Texas, he conceded that in these early years he had the firm conviction that he had “to keep psychiatry virginal, free of intruders, who would not understand what we were up against.”56 In the same lecture at Baylor, he also talked about his “deplorable lack of understanding of the whole situation,” and confessed that “there were social workers of whom I never had seen one before, and who did not fit in my ‘continental’ scheme. Further, I declined to apply for grants and refused whatever was connected with such application. This would in my ‘continental’ conviction not be the business of the professor.” In addition, there were problems inherent in the design of the Institute that contributed to the ensuing difficulties. Too many of the original Institute faculty brought their own research with them and never gave a thought to collaboration. For example, 80 percent of the money raised by Institutefunded projects was initiated by individuals, not by collaborative groups.57

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Despite geographic proximity and professed interest, the proclaimed “larger pattern” of work did not emerge in the first years of the Institute’s existence. Three explanations for this failure were given by the protagonists: the distribution of funds to individuals or departments inhibited the voluntary association of scientists, the sensationalism of the applied work overshadowed the slow and subtle progress in scientific theory, and the tendency of established, mature scientists to continue working independently in accustomed ways.58 The critical evaluation by the university bodies involved and by the Rockefeller Foundation led to plans for a restructuring of the Institute. In October 1932, Mark May, professor of pedagogics and, since 1930, executive director of the Institute, formulated a crucial question in an exchange with Angell: “How are we to conserve those elements of individual freedom, initiative, inventiveness, and imagination, which are regarded as essential in scientific discovery, and at the same time follow a formal program?”59 May developed plans for an integration of the various research plans and a “social systematization” of all the Institute’s activities.60 In 1935 a full reorganization of the Institute was put into practice, which at its core implied the transfer of funds from the department of psychiatry to the newly established office of the fulltime director of the Institute, Mark May. A number of young researchers were hired in the belief that they would be more flexible and more willing to engage in a cooperative integrated scientific endeavor than would the older scientists. At the same time, a number of units that resisted integration were shifted out of the Institute, in particular the Psychiatry and Mental Hygiene Department, the Child Guidance Clinic directed by Arnold Gesell, and Robert Yerkes’s primate laboratory.61 Together with this decision, Angell informed Kahn that the Institute’s facilities had been “designed . . . for a much more inclusive study of human behavior and human relations as that pursued in the psychiatry department.” Winternitz resigned his deanship in connection with the failure of his ambitious plans regarding the Institute. In his final Dean’s Report in 1935, he formulated the following summary regarding the psychiatric department: It was not considered of major importance that all students should learn how to classify the psychoses, but it was thought important that all should gain enough knowledge of mental disorders and enough interest in human personalities to be able to judge when the patient ought to be referred to the specialist in mental disorders. . . . It will be remembered that the department was financed as a part of the Institute of Human Relations and that the purpose of the whole project was and is to gain a better understanding of human beings as socially functioning individuals. . . . Stress was not placed upon dealing with mentally and emotionally defective persons, but rather upon discovering the factors upon which mental, emotional and physical health depend in the kind of society in which we live.62

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With this summary, Winternitz had also given a sketch of the two cultures of psychiatry that met with Kahn’s appointment. Derived from the mental hygiene approach and the social science perspective on medicine, the Yale program focused on the pragmatic concepts of adjustment and maladjustment of individuals in their social environment; in contrast, the Munich tradition had at its core the presupposition of mental illness as a biological deficiency, with only very limited scope of changes in its condition, but with an elaborated and idealistic meta-theory about the nature of psychiatric entities. Thus, the year 1935 represented a marked break in the department’s and the Institute’s development. The department was moved out of the center of the Institute’s organizational structure, and Kahn was now one professor amongst a number of others, subordinate to the new director of the Institute. Even then, Kahn was not willing or able to join in the cooperative research with the other divisions of the Institute. Instead, the initiative shifted to one of the younger researchers, foremost among them psychologist Clark Hall. He developed a detailed research agenda that was to be the crystallized core of coordinated investigations from the various disciplines. The general topic was the nature of motivation, and the phenomena to be approached from the different perspectives were altruism, imitation, and cooperation. The project required the experimental testing of hypotheses derived in part from psychoanalysis, and the receptivity to nonpsychological concepts such as culture, history, and social structure. Originally aimed at analyzing the shortcomings of Freudian theory, the common activities proceeded to an endeavor to make Freud’s work scientifically verifiable and logically coherent.63 But all this went on without any active participation of Kahn or the staff of his department. In fact, in 1938 the department was definitively transferred out of the Institute and fully integrated in the Medical School.64 Kahn succeeded in consolidating the psychiatric hospital and in the training of junior psychiatrists. He also published articles continuously, preferably on conceptual and methodological issues. But these were the results of his individual reasoning as a scholar—a kind of “research” that, at least until the 1950s, was well accepted in the community of German and Swiss psychiatrists. However, in the eyes of his colleagues at Yale, this was not the kind of research they expected or accepted. It was rather detached from empirical work, and it was neither interdisciplinary nor collaborative in the context of the Institute of Human Relations. Finally, in 1946, Kahn was urged to resign to create the opportunity for a new input from psychiatry into the Institute’s flourishing activities.65 Frederick Redlich, an Austrian émigré and until then an assistant in the department, was to become his more successful successor—it was to be the beginning of another chapter in the interrelation between German-speaking and American psychiatry.

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Epilogue As a result of the negotiations between the president of Yale and Kahn about the conditions of his resignation as chair, from 1946 onwards Kahn had the title of Professor of Clinical Psychiatry and Research Associate. This implied some clinical responsibilities, and ample time for writing and lecturing. From 1948 until 1950, he toured Europe and spent most of his time in Berne, Switzerland, where he had close contact with a number of Swiss psychiatrists that he got to know through his former Munich colleague Ernst Grünthal (who during the Nazi period had emigrated to Switzerland). In 1951, after his return to the States, he joined the department of psychiatry at Baylor University College of Medicine in Houston as a full professor. He remained on the staff until his retirement in 1962. During this time, he was a prolific writer on issues of psychiatric theory66 and on his discipline’s history.67 He also gave fortnightly lectures on these topics, which made him a much-respected and revered personality at Baylor.68 Kahn died in Houston in 1973, at the age of eighty-five.

Notes 1. See, for example, the contemporary admiration for Emil Kraepelin internationally as described in Smith Ely Jelliffe, “Emil Kraepelin, the Man and His Work,” Archives of Neurology and Psychiatry 27 (1932): 761–73; see also the chapters by Rhodri Hayward and John Burnham in this volume. Both chapters, however, also give evidence for more inward-turning tendencies in American as well as British psychiatry in the 1920s. 2. On German psychiatry in the interwar period, see Volker Roelcke, “Continuities or Ruptures? Concepts, Institutions, and Contexts of Twentieth-Century German Psychiatry and Mental Health Care,” in Psychiatric Cultures Compared: Psychiatry and Mental Health Care in the Twentieth Century, ed. Marijke Gijswijt-Hofstra et al. (Amsterdam: Amsterdam University Press, 2005): 162–82. On the debates about a “crisis of medicine,” the expression of a broader discontent within German medicine, see Carsten Timmermann, “Constitutional Medicine, Neo-Romanticism and the Politics of Anti-Mechanism in Interwar Germany,” Bulletin of the History of Medicine 75 (2001): 717–39. On Domarus, see Uwe Henrik Peters, “Die deutsche Schizophrenielehre und die psychiatrische Emigration,” Fortschritte der Neurologie und Psychiatrie 56 (1988): 349. 3. “Professor of Psychiatry Appointed at Yale,” American Journal of Psychiatry 86, no. 3 (November 1929): 585–86. 4. See Gerald N. Grob, Mental Illness and American Society, 1875–1940 (Princeton: Princeton University Press, 1983); the following is particularly indebted to the detailed reconstruction of the mental hygiene movement by Hans Pols, Managing the Mind: The Culture of American Mental Hygiene, 1910–1950 (PhD diss., University of Pennsylvania, 1997). For an account of the mental hygiene movement with particular attention to its

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adaptation of concepts from Europe and its impact on European developments, see the chapter by Hans Pols in this volume. 5. On the structure and practical impact of Kraepelin’s classification, see Volker Roelcke, “Unterwegs zur Psychiatrie als Wissenschaft: Das Projekt einer ‘Irrenstatistik’ und Emil Kraepelins Neuformulierung der psychiatrischen Klassifikation,” in Psychiatrie im 19. Jahrhundert: Forschungen zur Geschichte von psychiatrischen Institutionen, Debatten und Praktiken im deutschen Sprachraum, eds. Eric J. Engstrom and Volker Roelcke (Basel: Schwabe, 2003), 169–88. 6. See, for example, William F. Ogburn and Alexander Goldenweiser, The Social Sciences and Their Interrelations (New York: Houghton Mifflin, 1927). 7. See Arthur J. Viseltear, “Milton C. Winternitz, and the Yale Institute of Human Relations. A Brief Chapter in the History of Social Medicine,” in Social Medicine and Medical Sociology in the Twentieth Century, ed. Dorothy Porter, Clio Medica/The Wellcome Series in the History of Medicine 43 (Amsterdam: Rodopi, 1997): 32–58. 8. On the biographies of Angell and Winternitz, see “James Rowland Angell,” in A History of Psychology in Autobiography, vol. 3, ed. Carl Murchison (Worcester, MA: Clark University Press, 1936): 1–38; Walter Miles, “James Rowland Angell, 1869–1949—Psychologist, Educator,” Science 110 (1949): 1–4; Averill A. Liebow and Levin L. Waters, “Milton Charles Winternitz, 1885–1959,” Yale Journal of Biology and Medicine 32 (1959): 143–72; and Viseltear, “A Brief Chapter in the History of Social Medicine.” 9. See, for example, Charles Winternitz, “Medicine as a Social Science,” in The New Social Science, ed. Leonard D. White (Chicago: University of Chicago Press, 1930): 40–45. 10. Ibid., 43; Winternitz, “The Human Welfare Group,” Yale Alumni Weekly (7 March 1930): 686. 11. See, for example, Winslow’s American Public Health Association presidential address: Charles E. A. Winslow, “Public Health at the Crossroads,” American Journal of Public Health 15 (1926): 1075–85; Lewellys Barker, “The Neuropsychiatrist and the Study of a Person as a Whole,” New York State Journal of Medicine 22 (1922): 512–15; Lewellys Barker “The Social Significance of Medicine,” Medical Journal and Record 120 (1924): 53–56; and further references in Viseltaer, “A Brief Chapter in the History of Social Medicine,” 38. For the broader contemporary vision of a holistic approach to medicine, see Theodore M. Brown, “George Canby Robinson and ‘The Patient as a Person,’” in Greater Than the Parts: Holism in Biomedicine, 1920–1950, eds. Christopher Lawrence and George Weisz (Oxford: Oxford University Press 1998): 135–60. 12. This judgment is documented in the resolution of the Rockefeller Foundation’s Board of Officers to fund altogether $2.5 million to establish the “Yale University Institute of Human Behavior”: Yale University Library, Manuscripts and Archives (hereafter YULMA), Institute of Human Relations, document titled “Confidential,” dated 3 January 1929. 13. See the “Report of the Dean of Yale Medical School, 1921–1922,” YULMA, Medical School, Dean’s Records. 14. Ibid., letter of 13 May 1927. 15. Milton Winternitz, “Memorandum Concerning the Establishment of an Institute of Human Behaviour at Yale University, 1926,” YULMA, Dean’s Records, 40. 16. On the activities leading to the establishment of a department of psychiatry at Yale, see Jonathan W. Engel, “Early Psychiatry at Yale: Milton C. Winternitz and

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the Founding of the Department of Psychiatry and Mental Hygiene,” Yale Journal of Biology and Medicine 67 (1994): 33–47. The role of Kahn, his background in German psychiatry, and his specific contributions and failings as the first chairman of the department is, however, only mentioned in passing in Engel’s account (43–45). 17. See, for example, the letters of Winternitz to Abraham Flexner dated 15 April 1927 and 13 May 1927, YULMA, Dean’s Records, 40, 668, quoted in Engel, “Early Psychiatry,” 37. 18. Winternitz, “Memorandum.” 19. See Engel, “Early Psychiatry,” 37. 20. Ruggles to Winternitz, letter of 18 August 1925, YULMA, Dean’s Records, 40, 668. 21. Cobb to Winternitz, letter dated 2 March 1926, ibid., 665; see also Engel, “Early Psychiatry,” 38. 22. Engel, “Early Psychiatry,” 39. See also Houston Academy of Medicine, Texas Medical Center Library/John P. McGovern Historical Collections and Research Center (hereafter TMCL), Kahn papers, Kahn to Dean Winternitz, letter dated 21 June 1935, in which Kahn gives an account on the development of the department since 1921. 23. Viseltear, “Winternitz,” 41. 24. “The Yale Institute of Human Relations Established for the Study of Man’s Behavior with Gifts Representing a Capital of $ 7.500.000,” Yale Alumni Weekly (15 February 1929): 597–98. 25. A first outline of Kahn’s biography with a focus on his published work (but only very sketchy passages of his time at Yale) is given in Erwin Schlaudt, Das wissenschaftliche Werk Eugen Kahns (MD diss., Mainz University, 1976). A rather personal account of Kahn is presented by his former Munich colleague and friend Ernst Grünthal in the preface of a volume dedicated to Kahn’s seventieth birthday in Beiträge zur Geschichte der Psychiatrie und Hirnanatomie, eds. Alfred Glaus, Ernst Grünthal, et al. (Basel: Karger, 1957), untitled preface, 6–9. For a short obituary, see Alex D. Pokorny, “Eugen Kahn 1887–1973,” American Journal of Psychiatry 130 (1973): 822. In the historiography of psychiatry, Kahn is almost forgotten. Thus, Uwe Henrik Peters, otherwise a knowledgeable source on the biographies of émigré German psychiatrists, incorrectly locates Kahn’s German background in the Heidelberg school of psychopathology. See Peters, “Schizophrenielehre,” 349. If not indicated otherwise, biographical data is taken from the thesis of Schlaudt and the personal file of Kahn, Archiv der Ludwig-Maximilians Universität München (file N-I-100) (hereafter UAM, PF Kahn). 26. See, for example, Eugen Kahn, “Psychopathie und Revolution,” Münchner Medizinische Wochenschrift 66, no. 2 (1919): 968–69; Kahn, “Psychopathen als revolutionäre Führer,” Zeitschrift für die gesamte Neurologie und Psychiatrie 52 (1919): 90–106. 27. See, for example, Eugen Kahn, “Über Zurechnungsfähigkeit bei Schizophrenen,” Monatsschrift für Kriminalpsychologie und Strafrechtsreform 14 (1923): 250–61. 28. For a reconstruction of Kraepelin’s nosology and classification, see Volker Roelcke, “Laborwissenschaft und Psychiatrie: Prämissen und Implikationen bei Emil Kraepelins Neuformulierung der psychiatrischen Krankheitslehre,”in Strategien der Kausalität: Konzepte der Krankheitsverursachung im 19. und 20. Jahrhundert (Neuere Medizin- und Wissenschaftsgeschichte, Quellen und Studien), vol. 5, ed. Christoph Gradmann and Thomas Schlich (Pfaffenweiler: Centaurus, 1999): 93–116.

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29. Hanns Hippius et al., Emil Kraepelin, Lebenserinnerungen (Berlin: Julius Springer, 1983). 30. Eric Engstrom, Clinical Psychiatry in Imperial Germany: A History of Psychiatric Practice (Ithaca: Cornell University Press, 2003). 31. Eric Engstrom, “Psychiatry and Public Affairs in Wilhelmine Germany,” History of Psychiatry 2 (1991): 111–32. 32. Volker Roelcke, “Biologizing Social Facts: An Early Twentieth Century Debate on Kraepelin’s Concepts of Culture, Neurasthenia, and Degeneration,” Culture, Medicine and Psychiatry 21 (1997): 383–403; and Roelcke, “Quantifizierung, Klassifikation, Epidemiologie: Normierungsversuche des Psychischen bei Emil Kraepelin,” in Normalität und Abweichung: Studien zur Theorie und Geschichte der Normalisierungsgesellschaft, ed. Werner Sohn and Herbert Mehrtens (Opladen: Westdeutscher Verlag, 1999): 183–200. 33. See Volker Roelcke, “Funding the Scientific Foundations of Race Policies: Ernst Rüdin and the Impact of Career Resources on Psychiatric Genetics, ca 1910– 1945” in Man, Medicine, and the State: The Human Body as an Object of Government Sponsored Medical Research in the 20th Century, ed. Wolfgang U. Eckart (Stuttgart: Franz Steiner, 2006): 72–87; Roelcke, “Die Etablierung der psychiatrischen Genetik in Deutschland, Grossbritannien und den USA, ca. 1910–1960. Zur untrennbaren Geschichte von Humangenetik und Eugenik,” Acta Historica Leopoldina 48 (2007): 173–90. 34. See Volker Roelcke, “Programm und Praxis der psychiatrischen Genetik an der Deutschen Forschungsanstalt für Psychiatrie unter Ernst Rüdin: Zum Verhältnis von Wissenschaft, Politik und Rasse-Begriff vor und nach 1933,” Medizinhistorisches Journal 37 (2002): 21–55; Hans-Jakob Ritter and Volker Roelcke, “Psychiatric Genetics in Munich and Basel between 1925 and 1945: Programs—Practices—Cooperative Arrangements,” Osiris 20 (2005): 263–88. 35. Eugen Kahn, Studien über Vererbung und Entstehung geistiger Störungen. IV. Schizoid und Schizophrenie im Erbgang. Beitrag zu den erblichen Beziehungen der Schizophrenie und des Schizoids mit besonderer Berücksichtigung der Nachkommenschaft schizophrener Ehepaare, Monographien aus dem Gesamtgebiet der Neurologie und Psychiatrie, vol. 36 (Berlin: Julius Springer, 1923). 36. As a result of his work, he proposed the classification of patients with schizophrenic symptoms into three categories: first, genuine schizophrenias; second, “schizoid reaction types,” or simply “schizoid,” which he defined as a partial expression of a schizophrenic disposition; and three, “schizoform reaction types” with an exogenous aetiology. For the first two of these categories, he suggested a distinct genetic causation which implied—in contrast to the previous work by Rüdin and others—the existence of two genetic units (“genes”), one of which would be transmitted in the recessive, the other in the dominant mode. The dominant gene determined the “schizoid” personality, but the combined occurrence of both genes was necessary to cause a genuine dementia praecox. The schizoid, on the other hand, he considered as a particular subtype of the psychopathic conditions, with no qualitative and only quantitative differences to normal mental states. 37. Eugen Kahn, “Psychopathien und psychogene Reaktionen,” Archiv für Psychiatrie und Nervenkrankheiten 80 (1927): 4–39; Kahn, “Ueber psychopathische Verläufe,” Münchner Medizinische Wochenschrift 74 (1927): 1404–6; Kahn, “Die psychopathischen

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Persönlichkeiten,” Handbuch der Geisteskrankheiten, vol. 5, Spezieller Teil 1, ed. Oswald Bumke (Berlin: Julius Springer, 1928): 227–487. 38. Wolfgang Burgmair et al., Emil Kraepelin, Persönliches: Selbstzeugnisse (München: Bellevue, 2000). 39. UAM, PF Bumke, Entnazifizierungsunterlagen. 40. This is supported by information from one of the “elder statesmen” of contemporary psychiatry, Pierre Pichot, who knew Kahn personally, and who stated to the author that due to Kraepelin’s anti-Semitism, Kahn refused to write a chapter on Kraepelin in a collection of psychiatrists’ biographies. Pichot to author, letter dated 2 August 2000. 41. See, for example, Eugen Kahn, “Die Psychopathien,” Fortschritte der Neurologie und Psychiatrie 1 (1929): 245–52; Kahn, “Ueber Wahnbildung,” Archiv für Psychiatrie und Nervenkrankheiten 88 (1929): 435–54. 42. Winternitz to Angell, letter dated 26 June, 1929; and Winternitz to Kahn, letter dated 26 June 1929, YULMA, Dean’s Records. 43. Winternitz to Angell, letter dated 16 September 1929. ibid. 44. Winternitz to Angell, letter dated 9 October 1929, ibid. 45. Eugen Kahn, Psychopathic Personalities, trans. H. Flanders (New Haven: Yale University Press, 1931). 46. Oswald Bumke, Gustav Kolb, Hans Roemer, Eugen Kahn, eds., Handbuch der psychischen Hygiene und der psychiatrischen Fürsorge (Berlin/Leipzig: de Gruyter, 1931). 47. See Pols, Managing the Mind; and Pols, “Divergences in American Psychiatry during the Depression: Somatic Psychiatry, Community Mental Hygiene, and Social Reconstruction,” Journal of the History of the Behavioral Sciences 37 (2001): 369–88. 48. Eugen Kahn, “Yale University School of Medicine, Department of Psychiatry and Mental Hygiene. Methods and Problems,” Medical Education 20 (1932): 69–72. 49. See also Kahn’s annual reports to the dean in: Eugen Kahn, letters to Dean Winternitz dated June 1, 1931; June 3, 1932; June 13, 1933, TMCL, Kahn papers. 50. Eugen Kahn, “Modern Problems in Psychiatry,” Mental Hygiene 14 (1930): 791–97. 51. Eugen Kahn and Raymond Dodge, The Craving for Superiority (New Haven: Yale University Press, 1931); Eugen Kahn and Louis H. Cohen, “Conflict and Integration in Schizophrenic Development,” American Journal of Psychiatry 11, no. 88 (1932): 1025–34. 52. Eugen Kahn and Louis H. Cohen, “The Potentiality for Change in Personality,” American Journal of Psychiatry 12, no. 90 (1932): 523–29; Eugen Kahn, “Adjustment and Its Limits,” American Journal of Psychiatry 94 (1937/38): 1277–90. 53. Eugen Kahn, “Adjustment and Its Limits,” 1281. 54. Meyer to Kahn, letter dated August 1931, Adolf Meyer papers, University Archives, Johns Hopkins University. 55. See the annual reports 1931–36, Kahn to Dean of the Yale Medical School, in TMCL, Kahn papers. 56. Eugen Kahn, unpublished manuscript, copy in possession of the author. I am grateful to Eugen Kahn’s family, and in particular Dr. Neil Kahn, Atlanta, Georgia, for giving me access to the papers of his grandfather and the permission to quote from them.

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57. Mark May to James Angell, 28 October 1932, YULMA, Angell Papers, 109, 1109, quoted in Viseltear, “Winternitz,” 47. 58. Jill G. Morawski, “Organizing Knowledge and Behavior at Yale’s Institute of Human Relations,” Isis 77 (1986): 231. 59. Viseltaer, “Winternitz,” 47. 60. Quoted in Morawski, “Organizing Knowledge,” 232. 61. Ibid., 232; Engel, “Early Psychiatry,” 44–45. 62. Quoted in Engel, “Early Psychiatry,” 45. 63. See the detailed reconstruction of this period, which is the focus of Morawski, “Organizing Knowledge.” 64. See Kahn’s annual report to Dean Bayne-Jones, dated June 29, 1938; references to discussion on this transfer are already to be found in the two previous annual reports of 1936 and 1937, TMCL, Kahn papers. 65. Letter of Seymour to Kahn, 15 July 1946; the preceding discussions within the medical school, and between the dean of the School of Medicine and Yale president Seymour are documented in a memorandum by Dean Francis Blake, dated 21 June 1946, and a letter of Blake to Seymour, dated 1 July 1946, YULMS, Medical School, Dean’s Records. 66. See, for example, Eugen Kahn, “An Appraisal of Existential Analysis, Two Parts,” Psychiatric Quarterly 31 (1957): 203–27, 417–44; Kahn, “The Stun,” American Journal of Psychiatry 118 (1962): 701–4; Eugen Kahn and Alex D. Pokorny, “Concerning the Concept of Schizophrenia,” American Journal of Psychiatry 120 (1964): 856– 60. 67. See, for example, Eugen Kahn, “On Incest and Freud´s Oedipus Complex,” Confinia Psychiatrica 8 (1965): 89–101; Kahn, “Benjamin Rush. The Founder of American Psychiatry,” Confinia Psychiatrica 10 (1967): 61–76. 68. Until today, there exists an annual Eugen Kahn lecture, and an Eugen Kahn lecture hall, at Baylor. I am grateful to Alex Pokorny and James Lomax, Baylor College of Medicine, Houston, Texas, for providing this information to me.

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Chapter Nine

Explorations of Scottish, German, and American Psychiatry The Work of Helen Boyle and Isabel Hutton in the Treatment of Noncertifiable Mental Disorders in England, 1899–1939 Louise Westwood State controlled care of the insane in Britain at the start of the twentieth century is often described as conservative because the emphasis was on certification and institutionalization for rate-aided patients.1 However, Britain cannot be considered as a whole because the laws governing mental health care were different in Scotland and England. Toward the end of the nineteenth century Scotland had temporary care for noncertifiable mental cases and community guardianship schemes for nonviolent cases of insanity.2 In 1894 Dr. John Carswell wrote that the General Board of Lunacy had “permitted the use of one male and one female ward in Barnhill Parochial Hospital for the treatment of doubtful and temporary non-certified cases.”3 In England borderline conditions were not acknowledged and prophylaxis and outpatient facilities were rare. This situation was the exact opposite of the psychiatric practice developing in Germany. The main protagonists in this chapter explored these German developments for their own clinical practice. Dr. Helen Boyle (1869–1957) and Dr. Isabel Hutton (1887–1960) traveled extensively in Europe and the United States in search of new ideas and good practices in an effort to improve the treatment of acute, temporary, and noncertifiable mental disorders in England.

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The Law, Psychiatric Clinics, and the Treatment of Noncertifiable Mental Disorders Under the 1890 and 1891 Lunacy Acts for England and Wales there was no possibility of treatment in a public asylum without certification; hospitals admitting mental patients had to be approved and registered by the regulating authority and nursing homes were not allowed to take mental cases.4 Dispensaries were new to the nineteenth century and a few asylums and general hospitals had them for mental disorders, but they were rare outside London.5 St. Thomas’s and the Charing Cross Hospital had clinics for mental disorders. In 1890 Dr. L. S. Forbes Winslow opened a charitable outpatient clinic in Euston Road, London for the mentally disordered poor, which was known as the British Hospital for Nervous Disorders.6 Psychiatric clinics supported by public funds were opened after the First World War in Cardiff, Oxford, and Cambridge, largely due to the experience of military doctors who were keen to use their expertise in civilian care.7 War neuroses could be treated without certification under the 1915 Mental Treatment Act, which was passed as a temporary measure for the duration of the war and for patients suffering from its effects thereafter, but this provision did not apply to civilians.8 The Tavistock (established in 1920) and the Maudsley were the most well-known psychiatric clinics in London.9 Special statutory powers were obtained for the treatment of voluntary rate-aided patients under the London County Council (LCC) Act of 1915, which enabled the Maudsley to take civilian patients without certification, but this provision was delayed until 1923 because of the war. In 1924 all London mental hospitals under LCC authority were allowed to take voluntary boarders.10 In 1929 Sir Hubert Bond, a senior Board of Control official, said that it was impossible to do without certification of the voluntary patient.11 However, Dr. Helen Boyle argued that voluntary, uncertified admission was absolutely necessary for the poor and that except for a few cases in London (a reference to the special powers of the LCC) the voluntary boarder system as it stood was only for the rich. The 1930 Mental Treatment Act allowed voluntary admission without certification for up to six months but many campaigning reformers believed that the Board of Control had managed to maintain its power over hospitals and patients. The 1930 Act also failed to address the social stigma of asylum admission, unlike Carswell’s Barnhill experiment in Scotland forty years before, because patients admitted under this act remained in the mental hospitals.12 The reformers were dissatisfied with the new law and the Rt. Hon. Josiah Wedgwood wrote that “there has been a wholesale surrender of the rights and liberties of the subject to enlarge the tremendous powers already possessed by that most autocratic of all organizations, the Board of Lunacy Control.”13 The

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1930 Act did, however, empower local authorities to provide psychiatric outpatient clinics, which acknowledged the need for prophylaxis and early treatment. By 1939 there were approximately 167 clinics, but the majority of these were under the auspices of the local mental hospitals.14

Dr. Helen Boyle and Her Vision for Early Nervous Disorders Alice Helen Anne Boyle was born in Dublin, educated partly in France and Germany, and studied medicine at the London School of Medicine for Women. She was fond of remarking that her MD, with distinction, was taken in Brussels because “it was the cheapest available.”15 Boyle began her career at the Claybury Asylum in London and also worked at the Canning Town Medical Mission in London’s East End. It was here that she observed patients with early signs of mental disorder and no hope of treatment until they were consigned to the asylum. Toward the end of the nineteenth century, Boyle moved to Brighton, a healthy seaside resort on the south coast, and set up a private practice with Dr. Mabel Jones.16 In 1899 they began a dispensary for poor females and they opened a hospital in 1905 for “early nervous disorders in women and girls.”17 Boyle believed that insanity could be cured or relieved if the condition was caught early and wrote, “insanity begins before a person is insane, and it is then that recognition and skilled treatment are most valuable.”18 Helen Boyle’s vision for the future was “not monstrous county asylums, but a development of the cottage system.”19 She propagated a social relationship between the hospital, patients, and staff; patients were encouraged to visit the hospital after discharge, take part in the hospital’s social events, and a few were given paid work. Boyle also took a holistic approach in treating a wide range of disorders unrelated to mental health because she believed that general health issues and environmental factors could exacerbate the mental condition.20 Boyle criticized the medical profession for treating patients in “bits and pieces” and would neither call herself a neurologist nor a psychiatrist.21 After 1912, Boyle’s establishment became known as The Lady Chichester Hospital (LCH) and it was unique in treating nervous disorders in poor female patients.

Influences and the Search for Solutions Boyle began an exploratory tour in 1905, visiting Dr. John Carswell at the Barnhill Hospital in Glasgow where the patients in the observation wards were described as “doubtful and temporary non-certified cases.”22 Twentysix years later, in 1931, Carswell’s obituary pointed out the significance of

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his work: it was unique in Scotland at the time and could not be pursued in England “until recently when the law has been amended to allow mental hospitals to admit voluntary patients.”23 Boyle also visited psychiatric establishments in Berlin, Göttingen, and Munich to explore clinical practices.24 The system in Germany was very different from the one in England because psychiatric polyclinics (outpatient facilities) were established at most universities during the 1890s and early 1900s. Engstrom argues that these clinics demonstrated the “social utility of the psychiatric profession and dismantled the barriers of mistrust and prejudice separating mental hospitals from society at large.”25 Engstrom also suggests that the German polyclinic was a bridge that enabled psychiatric expertise to “reach patients and relatives without resorting to formal institutionalization.”26 Boyle understood the public’s fear and mistrust of mental hospitals in England and she distanced herself from the system, which reinforced her reputation as a doctor who would provide treatment and care without formal institutionalization. In 1905 Boyle wrote to Emil Kraepelin (1856–1926), professor of psychiatry at the University of Munich, requesting an appointment to visit his clinic and discuss the arrangements for the care and treatment of “early mental cases . . . your work & name being already very well known in London.”27 Boyle was also very impressed with the clinics of Professor Theodor Ziehen (1862–1950) in Berlin and Max Laehr (1865–1936) in Zehlendorf, near Berlin.28 Laehr’s clinic was semicharitable and used occupational therapy as part of the treatment; patients were taught brushmaking, bookbinding, carpentry, and gardening.29 Boyle was most impressed by the clinic at the Provincial Sanatorium for Nervous Patients at Rasemühle, near Göttingen, which was maintained by public funds under the direction of Professor August Cramer (1860–1912).30 The Rasemühle clinic, established in 1901, was started to provide a source of acute, noncertifiable mental disorders for medical students. Cramer was also the superintendent of the local asylum; therefore a close working relationship was inevitable between the two establishments. However, he called his clinic “Nerven-Klinik” to encourage patients to seek treatment.31 According to Engstrom this clinic was unique at the time because it was specifically for lower-class patients and was built small and homely, more like a modest hotel than an asylum. Boyle’s hospital was also very small; it had ten beds initially and only thirtynine beds by 1925. It was located in a residential area, had an open-door policy, and did not certify patients. Occupational therapy and community activities were an important part of the care at the LCH and patients learned new skills and helped to run the hospital. This therapeutic agenda appears to have been influenced by German psychiatry’s “assumption that work . . . was the most effective means of treating nervous disorders in the lower classes.”32 Nevertheless Boyle used this therapy for all classes of patients because she believed that the Weir Mitchell Rest Cure encouraged too much

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introspection.33 Although the clinical practice at Boyle’s hospital was similar to the work at the Rasemühle clinic, the LCH had no connection with the local asylum or university or any other teaching facility, unlike the German polyclinics, which had a crucial pedagogical function. Carl Westphal founded the first academic psychiatric polyclinic in Berlin in 1872 to investigate borderline conditions between “normal” and “insane.” Engstrom provides evidence of the regular use of the term Grenzzustände (borderline conditions) from the end of the nineteenth century in Germany, where there was growing interest in nervous disorders.34 The language used in psychiatric care for wealthy patients in England at this time is full of euphemisms designed to avoid labeling a patient insane, for example: shattered nerves, nervous breakdown, melancholia, exhaustion, broken health, nervous collapse, and the more medical sounding neurasthenia.35 The function of this language was to distance the condition from insanity and the legal implications that could result in certification. Engstrom points out that the German polyclinics were not for those with mental illness that could be defined in medical or legal terms and that “state regulations governing admission to psychiatric hospitals were not enforced in polyclinics.”36 Boyle worked in England without the power of a university clinic behind her and used the language of the noncertifiable conditions as a tool to avoid interference by the regulating authority on the care and control of the insane. Patients’ conditions were described as “early nervous disorder,” “early cases of insanity,” “early nervous and mental cases,” “recoverable cases,” “rescuable cases,” and “borderland,” and she argued that they were not certifiable conditions and were therefore outside the jurisdiction of the Board of Control.37 In a letter to the Ministry of Health in 1932, Boyle wrote that any connection with the board would “prejudice the hospital and impair our usefulness to the very early cases of nervous trouble.”38 Boyle’s fears were entirely justified. The opinion of the board can be seen in a report from July 1932: We have shown considerable indulgence toward this place. . . . A great deal of nonsense is talked about “nervous” disorders and the term is frequently used to camouflage insanity, including cases which are certifiable and ought not to be treated except under the provisions of the Lunacy Act, 1890.39

Boyle’s explorations of German and American psychiatry provided her with plenty of ideas for change of the asylum culture in England and she gave evidence to the Royal Commission on Lunacy and Mental Disorder in 1925, but the progress she desired was not forthcoming and the subsequent Mental Treatment Act of 1930 was disappointing.40 Under the 1930 Act voluntary patients could be admitted only at board-approved hospitals, but the LCH did not have this approval. However, by 1932 the Brighton local

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authority was sending voluntary patients to the LCH. The Board of Control was incensed by this challenge to its authority and the whole matter was referred to the Ministry of Health.41 After 1930, the board allocated grants to clinics but the LCH received nothing. Boyle would not allow the board access to her hospital because she feared interference from this autocratic organization.42

From Practical Treatments to Psychotherapy The surviving annual reports of the LCH from 1905 provide a tantalizing hint that Boyle was experimenting with psychotherapy, but there is no firm evidence until 1920.43 In England psychoanalysis was treated with skepticism and this may explain Boyle’s cautious approach, but her friend Dr. Constance Long was bolder and in 1914 she summed up the widespread attitude to psychoanalysis, saying that in speaking of the unconscious to colleagues it was not unusual to see a shiver pass over them as if something uncanny had been touched, something of which they were dimly aware and not a little afraid. The fear came from the unconscious itself and was evidence of the bias, which existed therein against a view too exclusively scientific.44

Dr. Constance Ellen Long (1867–1923) began her medical training in 1891 at the London School of Medicine for Women. She specialized in obstetrics and sick children and was “one of the first exponents in this country of the analytical views of Jung and the Zurich school.”45 Her early interest began with Freud and she was one of the original nine founding members of the London Psycho-Analytic Society.46 Long visited Jung in Zurich in November 1913 and Ernest Jones wrote of his concerns to Freud, who replied, “he will be lost to you.” Jones answered, “Our member who goes to Jung is a woman, Constance Long, a virgin of 40, hence in any case not too hopeful.”47 At the beginning of 1914 Long visited Zurich again for five weeks of analysis, and Jung was a guest at Long’s home in July 1914. Noll argues that Jung’s visits to England, after his split with Freud, were part of a drive for dominance in the English-speaking world and Constance Long assisted these plans because she translated a collection of his papers on analytical psychology.48 In 1920 Helen Boyle outlined her use of psychodynamic therapies and also discussed the work of Charcot, Janet, and Freud when she gave a paper to the Medical Women’s Federation.49 It is clear from this paper that Boyle was eclectic in her approach, using light hypnosis, word association, free association, catharsis, and dream analysis. In 1939 Boyle acknowledged her debt to Dr. Constance Long for her early interest in the development of

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psychotherapy.50 Constance Long was part of the network of friends and colleagues who assisted Boyle’s work; their experience was drawn upon for a broad range of health issues, which again highlights Boyle’s holistic approach to mental health. Between 1912 and 1925 the LCH had a number of honorary consultants who were not psychiatrists, for example: Dr. Christine Shearer, an anesthetist, Mrs. Jeffries, a gynecologist, Miss Louisa Aldrich Blake, a surgeon, and Dr. Jane Walker, a TB specialist. The hospital’s honorary consultants were exclusively female, which reflects not only Boyle’s belief that women should be treated by women doctors but also her support of medical women who held a difficult minority position in the profession in Britain.51 Boyle left no record of her thoughts on the position of women in medicine even though her whole career followed a separatist tactic in dealing with women and children and female doctors. Dr. Isabel Emslie Hutton was more outspoken than Boyle on this matter and she too followed a career in psychiatry with an emphasis on the noncertifiable mental disorders.

Isabel Emslie Hutton: Psychiatrist, War Veteran, and Author Isabel Emslie studied medicine at Edinburgh University. She qualified in 1910 and worked initially at the Stirling District Mental Hospital in Scotland. In 1912 she was awarded her MD for research into general paralysis of the insane (GPI) and was the first woman to be appointed as physician in charge of women at the Morningside Royal Mental Hospital in Edinburgh. Many of the patients at the Morningside were uncertified and voluntary, which was peculiar to the Scottish system at the time.52 Emslie’s first publication was an observation of the effects of war on female civilian patients, and this paper suggests a developing interest in psychoanalysis.53 Emslie joined the Scottish Women’s Hospitals (SWH), whose facilities and expertise were rejected by the War Office.54 The allies eagerly accepted the expertise of the SWH and Emslie was sent to France in August 1915; three months later she was working in Serbia. She spent five and a half years with the SWH and left Constantinople on Christmas eve 1920 to begin her journey home.55 She traveled to Belgrade, where she visited a private clinic, and then on to Vienna where she studied “nervous and mental diseases, as it had been my specialty before the war.”56 She spent a month at the clinic of Professor Jauregg von Wagner (1857–1940), where she observed the malarial therapy for GPI.57 Emslie returned to her position at the Morningside Mental Hospital in Edinburgh but very soon married Major Tom Hutton and moved to London. Dr. Hutton began a private practice and attended lectures at the Maudsley Hospital, where she was offered a one-year research appointment on GPI. During the next few years Hutton obtained honorary (unpaid) appointments at the Maudsley and the West End Hospital, and she began to write

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medical books for the lay reader because she wanted to be financially independent. Hutton traveled to Germany and Austria with her husband, and she worked in Albania treating malaria sufferers.58 In some rough jottings made during a trip in 1923, she writes: “people say we are mad to go to Germany at such a time mark 1000 millions to the English pound: severe trouble in the Ruhr, revolutions in the air; black bread and starvation,” but this did not deter them.59 Hutton visited the department of psychiatry in Munich, hoping to see Emil Kraepelin, but he had retired from the university and instead she joined Dr. Otto Wuth (1885–1946) on his rounds. She was very impressed with this clinic, which was a teaching facility, and wrote that the observation wards were “well kept and well cared for—the linen spotless— this all due to the great care of the religious sisters who work all the time.”60 She also wrote that there were women nurses on the male side and twenty to thirty qualified doctors working in the laboratories.61 The following week Hutton had a two-hour meeting with Kraepelin at the German Institute for Psychiatric Research, where he remained as a director after his retirement.62 Hutton points out in her journal that their discussion on clinics, dementia praecox, and GPI were conducted entirely in German. She wrote: All went well for half an hour or so and then he began talking of the war and of how England forced Germany to fight and . . . of how insultingly they had spoken of Germany since the war and tirades on Lloyd George and Baldwin. It was really most uncomfortable. . . . Tirade number two was against all psychiatrists in England; of neurologists he had nothing but the best to say and spoke of Henry Head (perhaps they had come to Munich to sit at his feet) seriously however, the neurologists are a much better set than the psychiatrists, who are fat and lazy and self complacent. The young ones too, as at the Maudsley and other English Asylums think they are the last word in perfection—very sad. He said that English psychiatrists had lagged much behind. ‘Mein Gott’ said he ‘when we read that Journal von Mental Science we wonder if we have picked up a copy of forty years ago by mistake, they talk there of problems already settled years ago on the continent.’63

Kraepelin also told Hutton about his contact with the psychiatrists who were planning the Maudsley Hospital and she wrote in her journal that he had helped them all he could at Munich (i.e., at the time they were thinking of building the Maudsley). When they got back, however, he [Kraepelin] read that they had seen nothing at Munich that was new or of any use to them—he was very bitter about that.64

In 1925 Hutton was offered an honorary appointment at the British Hospital for Nervous Disorders, a poor charitable outpatient facility in north London.65 She was advised by Sir Frederick Mott and Dr. Mapother of the

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Maudsley not to accept the appointment because the hospital was unorthodox, almost unknown and without prestige. She was not dissuaded and, except for a period in India during the Second World War, she remained at the British Hospital until retirement.66 Outpatient care for mental and nervous patients dominated Hutton’s work, and in 1929 she wrote that the British Hospital clinic treated patients with nervous and mental disease while they carried on their ordinary lives. Hutton wrote that diet, sepsis, and other diseases could cause neurosis in women and that poor housing, overwork, too many children, and sexual difficulties, often caused by ignorance, were also responsible for mental health problems.67 Hutton’s commitment to this hospital confirms her interest in prophylaxis and she continued to visit psychiatric clinics abroad.68 During the summer of 1930 Hutton again traveled through Germany, visiting hospitals in Ansbach, Regensburg, and the Polyclinic at Freiburg. She later wrote to a colleague that the Freiburg clinic “is rather an untidy and badly run place but the teaching is very good indeed and there is plenty of material, as patients only remain until diagnosis is made and then go out to other institutions,” and also that Freiburg “interests itself in psychological study, especially of the Freudian School, as well as in all the other new lines of work.”69 By 1935 Hutton was vice president of the British Hospital and she subsequently wrote that it was at this clinic “that I found work that was preventative, far-reaching in its effects and an inestimable boon to patients and relatives.”70

The Battle for Equality and the Policy of Exclusion The battle for equal pay, equal status, and equal opportunities in medical training had been ongoing since the first woman was placed on the medical registry in Britain in 1859.71 Many medical schools did not accept women, women doctors were offered lower salaries, and the jobs available to women were restricted. The marriage bar had been relaxed during the First World War because of a shortage of workers but it was reimposed in the early 1920s for teachers and for other professions despite the 1919 Sex Disqualification (Removal) Act. This act was heralded as a “charter for freedom,” providing women with “equal opportunities, equal chances and equal rights with men,” but it contained many clauses and achieved nothing.72 The most infamous clause allowed the civil service to opt out of the obligations to admit women on equal terms. The treasury advised the entire civil service that all married women “from typists to the highest grade of workers were not to be employed.”73 The LCC and other government organizations, such as the post office, rigorously applied exclusion on the grounds of marital status, and Scottish government departments also

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had a marriage bar. A survey by the Medical Women’s Federation in 1921 found that women working for the Glasgow School Board had to resign on marriage.74 Married women doctors were, however, employed in a few parts of Britain, for example in Northumberland and Newcastle. In London the majority of appointments were through the LCC, the Ministry of Health, and other government agencies, and the competition for the best medical positions was fierce; this could explain the disparities in number between male and female doctors because a male-dominated profession was determined to protect its position in the capital. In 1922 Hutton was offered a full-time salaried, nonresidential position at the Maudsley, but just as she was considering the offer it was withdrawn because of her marital status. A letter to one of her referees explained “no exception could be made in her favor to the general rule of the LCC prohibiting the appointment of married women.”75 Her next attempt was with the Board of Control, which had already employed her for a year of research at the Maudsley. Hutton later wrote that the interview turned to “frigid politeness” when her marital status became evident and she was reminded of the absolute bar on married women in government service.76 Hutton’s work and independence were important to her because she was childless and, as an army wife, spent many months separated from her husband. The marriage bar was a source of frustration and anxiety and she became embroiled in a heated media debate during 1928/9. Hutton responded to an article in The Times, which stated that 50 percent of medical women, often the most brilliant, relinquished the profession after marriage. She widened the debate by comparing the treatment of women medical students in Britain and Europe. Medicine we are often told is an international science, and doctors, as such, have no nationality. This being so, might we not condescend to see what happens in the other countries of Europe? Women students are not barred from the great medical schools such as those of Vienna or Paris and married medical women are allowed to hold public appointments in many foreign countries, even the most primitive.77

She also wrote to the Daily Telegraph: We find that on marriage medical women are dismissed from every public appointment . . . and married medical women are ineligible for any such appointments irrespective of their qualifications, age or experience.78

The debate continued for nearly a year and also raised the issue of exclusion by the London teaching hospitals.79 The Evening Standard reported Dr. Hutton as saying that London “of all places in the world was so parochial in its outlook . . . the attitude toward women students has made us the laughing stock of Europe, nowhere else is there such an absurd system.”80

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Hutton observed that medical women in the United States and parts of Europe were receiving large salaries and achieving highly prestigious appointments. In 1932 she traveled alone to the United States to negotiate a book deal and to visit psychiatric clinics.81 She visited Dr. Adolf Meyer (1866–1950) at the Henry Phipps Clinic at John Hopkins Hospital in Baltimore, which had opened in 1913.82 The outpatient department interested her the most because she observed that teaching was conducted with medical students and social workers all working together. Hutton met Dr. Esther Richards and wrote that she was quite a junior and had only been in the work for eight years but “she is an Associate Professor and has a splendid salary easy hours and private consulting work—many women have good posts—one on the staff Dr. Baker a nice girl has only been five years a doctor and has an enormous salary.”83 The tone in Hutton’s journal is one of despair, and she exclaims “quelle chance d’avoir une poste pareille!”84 The lack of a permanent salaried position shaped Hutton’s life during the interwar years; these years were littered with disappointments because she was prevented from fulfilling her ambition to have a clinic for the poor with teaching facilities and beds. Hutton’s last attempt to obtain a paid appointment was in 1934 when she applied for a part-time position at St. Marylebone Institution. She visited the institution and was unimpressed with the doctor in charge and with his attitude to his patients: What a wonderful little teaching center that could be and what good work could be done there among those so-called observation cases from hysteria right up to pre-senility. . . . Indeed there was exceedingly interesting material and the whole resources of a huge institution to carry it out. . . . The situation is central and there is everything in its favor.85

Her report suggests a desire to expand the facilities of the British Hospital for inpatients and to develop a pedagogical function similar to the German polyclinics. However, her plans came to nothing because she was a married woman. The Medical Officer of the LCC rejected her application and wrote: Eligibility for appointment to the Council’s service is restricted so far as married women are concerned to those whose husbands are totally or permanently incapacitated by reason of physical or mental disability from supporting them, and in certain cases, those who have been deserted by their husbands.86

Hutton replied angrily that she was fortunate because she neither had a dependent husband nor was she a deserted wife; she offered to do honorary work, which was also rejected. It was common for new doctors to do honorary work initially, which for men usually led to a paid appointment, but for married women an honorary appointment was in many cases the only

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work available and they therefore relied on private practice for income. In 1938 Hutton’s husband was promoted to Major General and appointed to command the Eastern Independent District of India. Dr. Hutton accompanied her husband and the war delayed her return to England until 1946. In India Hutton started medical clinics for coolies, organized thrift shops, and became Director of the Indian Red Cross Welfare Service because her offer to serve as a consultant with the armed forces was rejected.

Conclusion In England before the First World War prophylaxis for mental disorders was treated with suspicion by charities and the general public. There was a general view that insane persons should be treated only in the asylum and mental health was not a popular cause for philanthropic action; the Charity Organization Society made fundraising very difficult for the British Hospital.87 This attitude can be seen in a letter to the society in 1895 in which the writer asks if “a lunatic’s outpatient hospital can be a genuine charity.”88 The Lunacy Commission, which became the Board of Control after 1913, was also suspicious of the treatment of rate-aided persons not under its jurisdiction. Helen Boyle and Isabel Hutton both made a positive choice to treat nervous disorders in the poor outside the asylum system. They both took a holistic, eclectic approach, using psychotherapy and community care, which was the antithesis of the board’s view that all patients with mental disorder should be certified and placed in an institution. They were extremely knowledgeable of clinical practices in Europe and the United States and tried to promote change in England. Boyle visited the States after the First World War and saw for herself the work of the National Committee of Mental Hygiene, which was founded by Clifford Beers in 1909. On her return to England she discussed Beers’s work with Sir Maurice Craig, an advocate of early treatment, and in 1922 they founded the National Council for Mental Hygiene. The British Hospital, where Hutton worked for thirty years, may have been the first charitable outpatient facility for mental disorders, and Boyle’s Lady Chichester Hospital was certainly unique in dealing with early nervous disorders in females without certification.89 Fundraising issues and financial concerns dominate the annual reports of both establishments because government funding was rare for this type of psychiatric work until more clinics opened in the years following the 1930 Mental Treatment Act. Prior to this date Boyle worked outside the law while trying to emulate the work of Dr. Carswell in Scotland and the clinics in Germany. She firmly believed that her clinical judgment was more useful for a patient’s treatment than the lunacy law regulations, which were enforced inflexibly; her attitude and work practice antagonized the Board of Control and deprived her hospital and patients of funding support.90

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The two establishments discussed in this paper are comparable with the polyclinics in Germany at the start of the twentieth century, but they worked without state support. The German clinics had the distinct advantage of being part of the state university’s research system, but they were not subject to the usual state regulations and bureaucracy on the care and control of the insane; the medical professionals therefore had more freedom to decide how and where a patient should be treated. The strength of the German academic psychiatrist’s position promoted innovative clinical practice and useful research without outside interference, and these clinics could be found all over Germany. In England only the Maudsley, backed by powerful men and wealthy benefactors, was given special powers in order to treat mental disorders without certification. Subsequently the mental hospitals in the London area were also allowed to take voluntary boarders without certification, and this remained the situation until the voluntary uncertified boarder system was established under the 1930 Mental Treatment Act. The work at the LCH preceded the Maudsley in treating uncertifiable disorders by almost twenty years, but little attention has been given to this pioneering work because it was performed outside the capital and supported and run by women with a low profile in society and the medical profession. In 1924 only 8 percent of doctors in Britain were female and they worked in very restricted spheres of medicine such as infant and child welfare and general practice, which increased competition for the low-status, low-paid jobs. The minority position of both Boyle and Hutton in psychiatric practice is evident, and the marriage bar in Britain was just another obstacle for women in the medical profession. Boyle’s founding of her own charitable hospital was a separatist tactic that had been used before to found schools of medicine for women in Edinburgh and London, and she created a network of female experts who were able to develop their own ideas for treatment and care without interference. The work at the LCH and the British Hospital was innovative and bares a striking resemblance to the modern systems of care in England: the large mental hospitals have closed in favor of smaller units with an open-door voluntary system for inpatient care; day care and outpatient care is the preferred system. Certification is now the exception rather than the rule, a policy that both Dr. Helen Boyle and Dr. Isabel Hutton pursued all their working lives.

Notes 1. See Anne Digby, Madness, Morality and Medicine: A Study of the York Retreat, 1796–1914 (Cambridge: Cambridge University Press, 1985); Jonathan Andrews, Asa Briggs, Roy Porter, Penny Tucker, and Keir Waddington, The History of Bethlem (London: Routledge, 1997); James Gardner, Sweet Bells Jangled Out of Tune: A History of the Sussex Lunatic Asylum (Brighton: Harvester, 1999).

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2. For further details on the Scottish system, see Harriet Sturdy and William Parry Jones, “Boarding-out Insane Patients: The Significance of the Scottish System 1857–1913,” in Outside the Walls of the Asylum: The History of Care in the Community 1750–2000, ed. Peter Bartlett and David Wright (London: Athlone, 1999); A. B. Sclare, “John Carswell, a Pioneer in Scottish Psychiatry,” Scottish Medical Journal 26 (1981): 265–70; John Carswell, “The History of an Experiment in Dealing with the Reported Cases of Insanity Occurring in the Barony Parish of Glasgow,” Journal of Mental Science 40 (July 1894): 394–475. 3. Carswell, “History of an Experiment,” 397. 4. Montague Lomax summed up the treatment of pauper lunatics as “drugging and purging” in Experiences of an Asylum Doctor (London: Allen & Unwin, 1921), 36–37. 5. See “An Out-patient Department at the Wakefield Asylum,” The Journal of Mental Science 36 (October 1890): 529–30; Irving S. I. Loudon, “Origins and Growth of the Dispensary Movement in England,” Bulletin of the History of Medicine 55, no. 3 (1981): 322–42. 6. Helen Boyle, “The Early Treatment of the Psychoses and Psychoneuroses,” British Medical Journal (24 November 1928): 923–26; See also London Metropolitan Archive, A/FWA/C/D198/1–2, “The Forbes Winslow Memorial Hospital,” Jewish World (4 July 1891). 7. T. S. Good, “The Oxford Clinic,” Journal of Mental Science 68 (January 1922): 17–23 and “Discussion on the Oxford Clinic,” Journal of Mental Science 67 (October 1921): 525–32. 8. Board of Control Annual Report 1914–1915, III, 54, Mental Treatment Bill. For more on this temporary measure see Mental Treatment Bill, 5 Geo 5 (Parliamentary Papers [hereafter PP] 1914–16, III); Report of the Royal Commission on Lunacy and Mental Disorder, Cmd. 2700 (PP 1926, XIII). 9. See Henry V. Dicks, Fifty Years of the Tavistock Clinic (London: Routledge, 1970); Trevor Turner, “Henry Maudsley—Psychiatrist, Philosopher and Entrepreneur,” Psychological Medicine 18 (1988): 551–74. On the Maudsley Hospital, see the chapter by Rhodri Hayward in this volume. 10. Report of the Royal Commission on Lunacy and Mental Disorder 1926, XIII, 373. Section 1, Historical Background. 11. “The Present Position of the Voluntary Boarder,” British Medical Journal (17 August 1929): 303–5. 12. Mental Treatment Act, 20 and 21 Geo (PP, 1930, V). 13. Contemporary Medical Archives Center at the Wellcome Trust for the History of Medicine, Euston Road, London (CMAC). SA/EUG/ D142. Media article collection. “New Lunacy Terror,” John Bull (24 May 1930). 14. National Archive. Kew, London. MH58/574. Directory of Outpatient Mental Treatment Clinics, 1941. 15. Louise Westwood, “A Quiet Revolution in Brighton: Dr. Helen Boyle’s Pioneering Approach to Mental Health Care, 1899–1939,” Social History of Medicine 14, no. 3 (December 2001): 439–57; “Care in the Community of the Mentally Disordered: The Case of the Guardianship Society, 1900–1939,” Social History of Medicine 20, no. 1 (April 2007): 57–72; “Obituary of Dr. Helen Boyle,” British Medical Journal (30 November 1957): 1310.

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16. For more on Brighton’s importance in the history of public health, see John. M. Eyler, Sir Arthur Newsholme and State Medicine 1885–1935 (Cambridge: Cambridge History of Medicine, 1997). 17. East Sussex Record Office in Lewes, East Sussex. (ESRO) HB63/1A. Annual Reports. 18. Helen Boyle, “Some Points in the Early Treatment of Mental and Nervous Cases (With Special Reference to the Poor),” Journal of Mental Science 51 (October 1905): 676–710. 19. “Report of a Meeting of the Women’s Local Government Society, Guardian (22 March 1905): 508. The Guardian was a Church of England weekly newspaper published from 1846 to 1951. 20. CMAC. SA/MWF/C21, Helen Boyle, “Some Observations on Early Nervous and Mental Cases with Suggestions as to Possible Improvements in our Methods of Dealing with Them,” Journal of Mental Science 60 (1914): 1–10, Reprint. 21. “Discussion,” Section of Neurology and Psychiatry, British Medical Journal (6 November 1920): 696. 22. Carswell, “History of an Experiment,” 397. 23. Obituary, John Carswell, The Lancet (27 June 1931): 1425. 24. See Eric J. Engstrom, Clinical Psychiatry in Imperial Germany: A History of Psychiatric Practice (Ithaca: Cornell University Press, 2003). 25. Eric J. Engstrom, The Birth of Clinical Psychiatry: Power, Knowledge and Professionalisation in Germany, 1867–1914 (PhD diss., University of North Carolina, 1997), 287 26. Ibid., 286–87. 27. Max-Planck-Institut für Psychiatrie, Historisches Archiv, München. (MPIPHA): K33/2 Boyle. Letter dated 8 July 1905 written at the Hotel de l’Europe, München. For more on Kraepelin, see German E. Berrios and Roy Porter, eds., A History of Clinical Psychiatry: The Origin and History of Psychiatric Disorders (London: Athlone, 1995), 261–92. 28. Boyle, “Some Points in the Early Treatment,” 678–79. 29. Ibid., 678. 30. Ibid., 679. 31. Engstrom, Birth of Clinical Psychiatry, 298. 32. Ibid., 307. 33. Some of Boyle’s patients were professional people but too poor to afford private health care. See Suzanne Poirier, “The Weir Mitchell Rest Cure: Doctor and Patients,” Women’s Studies 10 (1983): 15–40. 34. Engstrom, Birth of Clinical Psychiatry, chap. 9, “Social Prophylaxis: Psychiatric Polyclinics,” 285–312. I am grateful to Eric Engstrom for clarifying this point, as his thesis is in English. 35. See Janet Oppenheim, Shattered Nerves—Doctors, Patients and Depression in Victorian England (Oxford: Oxford University Press, 1991). For more on the use of the term neurasthenia, see Roy Porter and Marijke Gijswijt-Hofstra, eds., Cultures of Neurasthenia: From Beard to the First World War (Amsterdam: Rodopi, 2001); Barbara Sichermann, “The Uses of a Diagnosis: Doctors, Patients and Neurasthenia,” Journal of the History of Medicine 32 (1977): 33–54. 36. Engstrom, Birth of Clinical Psychiatry, 302.

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37. Boyle, “Some Points in the Early Treatment.” Boyle, “The Ideal Clinic for the Treatment of Nervous and Borderland Cases,” Proceedings of the Royal Society of Medicine 15 (1922): 39–48. Boyle, “Borderland Cases,” British Medical Journal (27 March 1920): 438. The term borderland was used in mid-nineteenth-century England. See Andrew Wynter, The Borderlands of Insanity and Other Allied Papers (London: Robert Hardwicke, 1875). 38. National Archive. MH58/77/95009/3/23, 23 June 1932. 39. Ibid., Minute sheet from the Board of Control, 19 July 1932. 40. CMAC. SA/MWF/21. Memorandum dated 20 May 1925. (Boyle’s evidence to the Royal Commission on Lunacy and Mental Disorder in 1925.) 41. National Archive, MH58/77/95009/3/23, 23 June 1932. 42. ESRO. HB63. See financial records of the Hospital. 43. ESRO. HB63/1A: Annual reports from 1905. Patient records have survived from 1920 but have only recently become available for researchers. A grant was awarded to the ESRO by the Wellcome Trust in 2006 to sort, preserve, and catalogue these records. 44. Report of the annual British Medical Association meeting where Jung gave a paper on “The Importance of the Unconscious in Psychopathology,” British Medical Journal (5 December 1914): 964–68. 45. Obituary, British Medical Journal (3 March 1923): 399. 46. Constance Long, “Introduction to the Study of Psycho-analysis in Charles Lloyd Tuckey,” Treatment by Hypnotism and Suggestion or Psycho-therapeutics (London: Baillière, Tindall & Cox, 1913), 353–77. 47. Richard Noll, The Aryan Christ: The Secret Life of Carl Gustav Jung (New York: Random House, 1997), 240, cited in R. Andrew Paskauskas, ed., The Complete Correspondence of Sigmund Freud and Ernest Jones, 1908–1939 (Cambridge: Harvard University Press, 1993), 242. 48. Carl G. Jung, Collected Papers on Analytical Psychology (London: Baillière, Tindall & Cox, 1917); See also Constance E. Long, The Psychology of Phantasy (London: Baillière, Tindall & Cox, 1920). 49. CMAC, SA/MWF/B2/1. Helen Boyle, “Psychotherapy, Its Scope and Dangers,” Medical Women’s Federation, Quarterly Newsletter (September 1920): 2–4. 50. Helen Boyle, “Watchman, What of the Night” (Presidential Address), Journal of Mental Science 85 (September 1939): 859–70 51. See Louise Westwood, “Separatism and Exclusion: Women in Psychiatry, 1900–50,” in Mental Illness and Learning Disability since 1850: Finding a Place for Mental Disorder in the United Kingdom, ed. Pamela Dale and Joseph Melling (London: Routledge, 2006): 91–111. 52. Private papers of Isabel Hutton held by her niece (hereafter PP Hutton). Obituary, The Times (12 January 1960); Isabel E. Hutton, Memories of a Doctor in War and Peace (London: Heinemann, 1960). 53. PP Hutton, Isabel Emslie, “War and Psychiatry” Edinburgh Medical Journal (May 1915); reprint. 54. For the history of the Scottish Women’s Hospitals, see Lena Leneman, In the Service of Life: The Story of Elsie Inglis and the Scottish Women’s Hospitals (Edinburgh: Mercat Press, 1994).

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55. See Obituary. Isabel Emslie Hutton was awarded five medals for her war service and was made an honorary associate of St. John of Jerusalem. 56. Isabel E. Hutton, With a Woman’s Unit in Serbia, Salonika and Sebastopol (London: Williams and Norgate, 1928), 288. 57. Wagner von Jauregg received the Nobel Prize for this work in 1927. 58. CMAC. SA/MWF/B2. Isabel E. Hutton, “An Anti-Malarial Campaign in Albania,” Medical Women’s Federation, Quarterly Newsletter (March 1926): 2–4. 59. PP Hutton, 23 September to 27 October 1923. 60. Ibid., 29 September 1923. 61. Ibid., 29 September 1923 and 1 October 1923. 62. See the chapters by Eric Engstrom and Volker Roelcke in this volume. 63. PP Hutton, 5 October 1923. 64. Ibid. 65. Although this facility was referred to as a hospital it had no beds for inpatient care. 66. For more on the British Hospital, see Louise Westwood, “Avoiding the Asylum: Pioneering Work in Mental Health Care, 1890–1939,” (DPhil diss., University of Sussex, 1999). 67. Isabel E. Hutton The Hygiene of Marriage (London: Heinemann, 1923); The Sex Technique in Marriage (New York: Emerson, 1932); Last of the Taboos: Mental Disorders in Modern Life (London: Heinemann, 1934); The Hygiene of the Change in Women (The Climacteric) (London: Heinemann, 1936); Women’s Change—Prime of Life, Making the Most of Maturity (New York: Emerson, 1937); Mental Disorders in Modern Life: An Outline for Hopeful Treatment (London: Heinemann, 1940). 68. See “Mental and Nervous Outpatients,” Ser. 2 (1929; repr.) XII. Written anonymously, but a copy was found among Dr. Isabel Hutton’s private papers and it is clearly referring to the British Hospital. 69. PP Hutton, Letters to Dr. A. E. Evans, 15 September and 22 September 1930. 70. Hutton, Memories of a Doctor, 220. 71. See Catriona Blake, The Charge of the Parasols: Women’s Entry to the Medical Profession (London: Women’s Press, 1990). 72. Dale Spender, Time and Tide Wait for No Man (London: Pandora Press, 1984), 129. 73. CMAC. SA/MWF.B2. July 1921. 74. Ibid. 75. PP Hutton, Letter dated 27 December 1922. 76. Hutton, Memories of a Doctor, 213. 77. PP Hutton, “Women Medical Students,” The Times (26 March 1928). 78. Ibid., “Women in the Medical Profession, Should Marriage be a Bar?” Daily Telegraph (26 March 1928). 79. See Carol Dyhouse, “Women Students and the London Medical Schools, 1914–39: The Anatomy of a Masculine Culture,” Gender and History 10 (April 1998): 110–32; No Distinction of Sex? Women in British Universities 1870–1939 (London: UCL Press, 1995). 80. PP Hutton, Evening Standard (7 January 1929).

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81. Hutton, The Sex Technique in Marriage; PP Hutton, American Journal (6 October 1932). 82. See Michael Gelder, “Adolf Meyer and His influence on British Psychiatry” in 150 Years of British Psychiatry 1841–1991, ed. German E. Berrios and Hugh L. Freeman (London: Gaskell, 1991), 419–35. 83. PP Hutton, American Journal (6 October 1932). 84. Ibid., “What luck to have a position like that!” 85. Ibid., “Visit report on the Marylebone Institution,” 15 May 1934. 86. Ibid., letter from Sir Frederick Menzies, 8 March 1934. 87. For more on the Charity Organisation Society and this opposition, see London Metropolitan Archive (LMA): A/FWA/C/D198/1–2; see also Robert Humphreys, Sin, Organised Charity and the Poor Law in Victorian England (London: Macmillan, 1995). 88. LMA. A/FWA/C.D198/1–2, letter dated December 7, 1895. 89. A few annual reports from the British Hospital have survived and are held at the St. Mary’s Hospital Archive, Praed Street, London. 90. Boyle, “Some Points in the Early Treatment.” See discussion and comments on the legal situation by Dr. John Carswell, 707.

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Chapter Ten

Welsh Psychiatry during the Interwar Years, and the Impact of American and German Inspirations and Resources Pamela Michael In assessing German and American influences on “British” psychiatry in the interwar years it is important to recognize that the British Isles comprise four nations: England, Ireland,1 Scotland, and Wales. Scotland and Ireland operated under separate legislative and administrative structures regarding care of the insane, but England and Wales were under one and the same jurisdiction. Although there were significant differences between England and Wales in terms of history, culture, language, economy, and social structure, both were subject to the same laws and administration for poor law and lunacy. Therefore it is difficult to discuss Welsh psychiatry as a distinct entity. However, a focus on changing provisions and treatments for the mentally ill in Wales during the interwar years does make it possible to explore the influence of German and American psychiatry at a sub-national level and counterbalances the tendency of much medical historiography to focus on the English metropolis and on unrepresentative institutions such as the Maudsley Hospital.

The Cardiff City Mental Hospital By the time of the First World War there were five county or joint-counties asylums in Wales, most of them dating from the middle of the nineteenth century. These Victorian-style asylums had accumulated large populations of chronic, long-stay patients, making change and modernization difficult to implement, so that efforts were concentrated on ensuring basic standards of

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care and provision. Partly in an attempt to distinguish itself from the existing “asylums” in Wales, the Cardiff City Mental Hospital, opened in 1908, set out to emulate models then current in European psychiatry. The establishment of a modern “mental hospital” was part of a wider political project to promote Cardiff as a city and to advance its claim to be the capital city of Wales. The hospital was equipped from the beginning with a research laboratory, and was staffed by a research chemist, a pathologist, and a bacteriologist. In 1911 the hospital obtained a licence to keep animals for the purpose of conducting medical experiments. This was at a time when very few psychiatric hospitals in the United Kingdom were conducting research into the causes of insanity. During the interwar years, the hospital’s laboratory staff would pioneer research in brain chemistry and achieve world renown.

Funding for Psychiatric Research in the United Kingdom—a Welsh-led Campaign In 1912, the Visiting Committee of Cardiff City Mental Hospital summoned a national convention to consider the desirability of pressing for central government grants toward the cost of researches into mental disease. The conference, held in London, was attended by delegates from fifty-three asylums across England and Wales. The Lord Mayor of Cardiff explained that the “English system of local government had delegated the administration of hospitals for the insane to local bodies, but often work might be done there that accrued to the benefit of the State.”2 Research work often demanded expenditure far beyond what could be reasonably expected of a local institution. Under the Insurance Act of 1911 the United Kingdom government granted a million and a half pounds to deal with tuberculosis, and a definite portion of that sum was earmarked for research. Government grants were also available for medical research in other areas, but not for investigation into insanity. A resolution placed before the convention urging that “State aid be given in the shape of grants toward specific scientific researches having for their object the prevention and cure of insanity” was carried unanimously.3 Alderman Thomas, Cardiff’s Lord Mayor, led a deputation to the lunacy commissioners and made representations to the Home Secretary. Thomas spoke of the work being done at Cardiff, declaring that the “first duty in that institution was to cure rather than to tame.”4 Sir George Savage called upon Parliament to provide direct assistance for research in mental science. Dr. Goodall, superintendent of Cardiff City Mental Hospital, pointed out that already “on the Continent state aid for this kind of research was given.”5 This lobbying met with success and, during a visit to Cardiff in 1913, the Home Secretary, Reginald McKenna, announced that the British government had decided on funding psychiatric research.6 As a result, Cardiff

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received international acclaim and was seen to be at the center of a movement to put British psychiatry on a par with continental Europe. In August that year the psychiatry section of the International Congress of Medicine met at Imperial College, London. Dr. Adolf Meyer, of Baltimore, and Dr. Robert Sommer, of Giessen, reported on “The Psychiatric Clinique: Its Aims (Educational and Therapeutic) and the Results Obtained.” Professor Janet, of Paris, and Dr. Carl Gustav Jung, of Zurich, spoke on psychoanalysis. Dr. Karl Bonhoeffer, of Berlin, considered the “psychoses of infection and auto-intoxication.” Dr. Edwin Goodall and Dr. Scholberg, of Cardiff, presented a paper “On Complement-Fixation, and on the Cell- and ProteinContent of the Liquor Cerebro-Spinalis.”7 About forty delegates visited Cardiff City Mental Hospital, led by Sir James Crichton-Browne, president of the psychiatry section. The group included distinguished medical scientists from “the colonies,” the United States of America, continental Europe, and other countries.8 The Lord Mayor hosted a civic reception and spoke of the “splendid work in mental research” being carried out by Dr. Goodall and his colleagues. In response, Sir James Crichton-Browne iterated the internationalist sentiment of the occasion: International medical congresses were peace congresses. Whatever the nationality of their members were, they were banded together in a common cause as an army against diseases. They who had come from London that day were spies, but in this case they were welcome spies (Hear, hear). They had come to make themselves acquainted with the good work which the benevolence of the city was doing against the most troublesome and formidable forms of disease.9

By 1913 Cardiff had positioned itself within a network of international research into mental disease. The First World War interrupted the continuity of such international gatherings and halted research work in Wales. The Cardiff City Mental Hospital was converted into a metropolitan war hospital, with Dr. Goodall in command. The hospital was finally returned to civilian use in 1920 and research work resumed. The First World War occurred at a critical time in the development of British psychiatry. The introduction of new psychiatric approaches was disrupted by the displacement of patients from many of the more modern hospitals in order to create space for war casualties. Pressure was put on hospitals receiving transfer patients, especially since they simultaneously lost many of their male staff to military service. Hence, the movement to facilitate the early treatment of mental disorders within the state-funded system in Britain was temporarily derailed. This interpretation is at variance with some recent accounts of the significance of the First World War for the development of psychiatry, which locate the origins of the new approach to mental disorders in the treatment of military casualties and the debates over shell shock.10

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The Early Treatment of Mental Diseases and the Establishment of a Psychiatric Clinic at Cardiff The early treatment of mental diseases was becoming recognized as an important goal amongst the British medical profession. It was strongly advocated by Dr. Robert Armstrong Jones, the Welsh medical superintendent of London County Council’s Claybury Asylum from 1893 to 1916. When Dr. Sydney Hughes, one of his Welsh-speaking assistants, moved to the North Wales Asylum at Denbigh in 1910, he took with him these ideas. The Denbigh hospital management committee was sympathetic to his proposals and requested plans for a new reception hospital for the treatment of cases of incipient insanity to operate in conjunction with a network of new outpatient clinics.11 Architectural specifications were prepared and building contracts about to be issued when war was declared. Postwar financial constraints delayed the resumption of these plans. In January 1914 Dr. Goodall, at Cardiff, spoke of the need for thoroughgoing reform of the existing system of British psychiatry to facilitate the “early treatment of incipient and undeveloped cases of mental disease,” and enable medical staff to deal with “acute and recent insanity on more scientific lines.”12 The existing legal system prevented a poor person obtaining treatment “except on the condition of deprivation of his liberty.” Goodall argued that nothing effectual could be done “until the law is altered, so that patients, who may be called candidates for insanity and borderland cases, may be able to attend out- and inpatient departments of the ordinary hospital or infirmary just like any other.” Patients should be dealt with “in blocks associated with ordinary infirmaries.” This, he said, was the principle of the psychiatric clinic, “which is adopted in practically all Continental countries, in our Colonies, and in America.” Ideally, they should be situated in university towns in connection with medical schools, and he cited the example of the psychiatric clinic at the University of Munich as a place of “world-wide renown amongst specialists.”13 After the First World War, Goodall reiterated his plea for an inpatient clinic in Cardiff, in association with the University, and in 1919 he called a conference to discuss the establishment of such a clinic. The meeting was attended by his own Visiting Committee and by representatives of the Board of Control (the successor to the Lunacy Commission), the City’s King Edward VII Hospital, and the local university. The Board of Control members expressed their sympathy with the object of the conference and elaborated the proposals embodied in the draft parliamentary “Early Mental Treatment Bill.” The projected reforms would allow for the provision of adequate facilities for reception and treatment of cases, either as inpatients or outpatients, alongside facilities for tuition and research. It was proposed to “relax the Lunacy laws so as to allow of the treatment of patients for a

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period of six months without the use of Judicial Orders and Certificates of Insanity and without legal formalities.”14 Unfortunately, this bold new legislation foundered, and whilst some of the recommendations were embodied in the miscellaneous provisions of the Ministry of Health bill presented to Parliament in 1920, the bill was rejected in the House of Lords. The Mental Treatment Act, which allowed for voluntary admissions to mental hospitals, was not finally introduced until 1930. In the meantime practical steps were taken in Cardiff with the establishment of a new Department of Psychiatry and outpatient departments at the King Edward VII Hospital. By December 1920 it was reported that the outpatient clinic was operational but that it was not possible to establish an indoor (inpatient) clinic until legislation was amended.15 Deliberations concerning such clinics continued and the following year Goodall attended a meeting in London called to discuss the setting up of psychiatric clinics and the work of the Mental Hospitals Association.16 A chance meeting with Sir Thomas Hughes, chairman of the Welsh Consultative Committee and the Welsh Board of Health, provided Goodall with the opportunity to set out his ideas for establishing an inpatient clinic in Cardiff in conjunction with the development of psychiatric education in Wales. Goodall explained his deeply held conviction that the “psychoses and psychoneuroses . . . should be dealt with on the same lines as other states of disease.”17 The establishment of the Welsh Board of Health under the terms of the Ministry of Health Act of 1919 had given Wales a measure of devolution with regard to health matters,18 and Goodall clearly considered it worth exploring the possibility of developing independent policies along more progressive lines: I think you know there is an out-patient Psychiatric Clinic weekly at the King Edward VII Hospital, Cardiff: this has only been running about two months, and there is already plenty to do there. As this is the only Clinic of the kind for the needs of, not only Cardiff, but also the dense population around, it may well grow to be a big thing in time. . . . When a Chair of Psychiatry is established . . . in Cardiff, the occupant will need an indoor clinic as well as this out-door one. . . . The out-patient Psychiatric Clinic was started after some propaganda work, in the hopes, not only that it would be in itself useful, but would also pave the way for an in-door clinic.

Goodall penned a hand-written sentence onto the typed letter, suggesting that “before establishing a Chair it would be a good plan to visit the Psychiatric Clinic of the John’s [sic] Hopkins University, Baltimore.”19 Previously Goodall had cited the examples of German psychiatric clinics, but here he was evidently hoping to improve the force of his persuasion by drawing attention to the leading American teaching institution, headed by Swiss psychiatrist Adolf Meyer.20 At this time the development of a Welsh school

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of medicine in Cardiff, along the lines of the “unit system” advocated by Flexner and pioneered at Johns Hopkins, was being considered.21 The “unit system” for teaching had been advocated by Sir William Osler, a member of the Haldane Commission appointed to look into the future structures of the federal University of Wales. Osler had left his post at Johns Hopkins to take up the Regius Chair of Medicine at Oxford in 1906, and in April 1913 he returned to Baltimore to attend the opening of the new psychiatric clinic, of which Meyer was director.22 Meyer took an active role in the training of medical students at Baltimore, where he established high standards of clinical practice and developed the theoretical approach of “psychobiology,” which involved focusing on the individual patient as a whole person. Edwin Goodall, who had been influenced by similar traditions, expounded Meyer’s principles and philosophy at the university in Cardiff.23 Despite the keenness of professionals in Wales to adopt models from Germany and the United States, only the Maudsley Hospital in London was able to take on such a role, since it had a unique legal status to accept voluntary patients.24 Goodall attended the opening ceremony at the Maudsley in 1923 and thereafter “was often to urge the establishment of a similar institution in Cardiff.”25 Neither this nor the creation of a chair in psychiatry at Cardiff occurred during Goodall’s career. He was asked to provide some instruction for medical students, but psychiatry did not fully develop as an academic discipline within the Welsh College of Medicine during the interwar period.

Psychotherapy The ideas of Adolf Meyer fitted comfortably alongside the practices of Welsh psychiatry, whereas those of Freud received a weaker reception in Wales. Of course, Freud’s ideas had limited influence in Britain generally, where initially they met with a sharp reaction amongst the more traditional sectors of the profession. Isabel Hutton described a meeting in Scotland in 1914, where many senior psychiatrists heard about Freud for the first time and “could hardly believe their ears.” Older members declared it to be “filthy,” “vile,” and “nothing but sex.”26 However, Freud’s theories awakened a broader interest in European thinking. One might have expected Freudianism to generate a warmer response in Wales. Ernest Jones, a native of Gowerton in south Wales, commenced his medical studies at Cardiff. He met Freud for the first time at the first International Psychoanalytical Congress in Salzburg, 1908. Jones claimed that Freud looked at him shrewdly, saying that judging by the shape of Jones’ head he certainly did not seem English—was he Welsh?27 Subsequently Freud wrote to Jung, remarking that “Jones is undoubtedly a very interesting and worthy

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man, but he gives me a feeling of, I was almost going to say, racial strangeness. He is a fanatic and doesn’t eat enough.”28 Jones became Freud’s foremost disciple in Britain, and in 1912 published the first major book in English on psychoanalysis.29 As Dean Rapp has argued, the popularization of Freud’s psychoanalytic ideas amongst the lay public in Britain did not lag significantly behind that of the United States.30 However, amongst the tightly knit profession of psychiatric practitioners in the UK, Freud’s ideas continued to receive anything but a rapturous welcome. The anti-German feeling that gathered strength during the First World War hardened this hostility, allowing Sir James Crichton-Browne to declare in 1920 his uncompromising conviction that “Freudianism” would “never take root in this country.”31 Likewise, Welsh psychiatrist Sir Robert Armstrong Jones was an implacable foe of Freudian psychoanalysis as not belonging to the “British character.”32 However, he held that whereas “Freudism . . . was dead,” psychoanalysis was “never more alive,” but had become “surrounded by a constellation not of ideas but of charlatanism.”33 Certainly, the culture of psychiatric work and education in Britain was hardly conducive to the adoption and practice of Freudian ideas. Ernest Jones described the features of a highly developed neurological science in England, but argued that psychiatry was almost nonexistent, and that it “was entirely subordinate to neurology and took its cue from the latter.”34 Malcolm Pines has argued that in America the reverse was true. For Ernest Jones, the intellectual encounter with Freud sealed his own fate as an outsider to the British medical establishment, a fate of which he was well aware. “I do not doubt that I should have gone far in the fields of medical and social psychology had Freud never lived,” he later remarked.35

Outpatient Clinics Ironically, it was in outpatient clinics that psychiatrists in Wales began to practice various forms of psychotherapy. Basing clinics in general hospitals tended to reflect a more somatic view of mental illness and the belief that mental disease should be treated much like any other form of illness. The clinic in Cardiff was only the fourth to be opened in a UK general hospital, with staff being provided by an associated mental hospital. By 1925, a total of sixteen general hospitals in England and Wales hosted an outpatient clinic for the treatment of mental cases.36 Later, between 1931 and 1935, other mental hospitals in Wales opened outpatients departments. During the 1920s a number of British psychiatrists spent periods practicing in the United States, from which they brought back new perspectives. In 1927 Ian Skottowe was appointed deputy medical superintendent at the Cardiff Mental Hospital. Formerly at the Boston Psychopathic Hospital, he

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had published an account of its methods.37 In Cardiff, Skottowe focused his attention on the work of the outpatient clinic, which in 1930 was regularly attended by three psychiatrists who met for a period of two to three hours weekly. A nurse and a trained social worker were essential members of the team, one of their important functions being the service they provided to the patient’s relatives and family. Skottowe described 60 to 70 percent of cases as comprising “psychoneuroses, mild or early psychoses, and behaviour problems,” regarded as eminently suitable for outpatient treatment. About 25 percent of the cases were supported by social service intervention. This type of intervention was viewed as not only having diagnostic value, but when properly used, as also being “a valuable therapeutic agent, particularly in behaviour problems.” According to Skottowe, psychotherapy was the most important form of treatment conducted in the clinics at Cardiff. However, since “most of the patients are not of a high intellectual status, persuasionist doctrines of Déjerine have been found most useful, adjuvated where necessary by the teachings of other schools.”38 These details illustrate how an outpatient department could open the way to innovative intervention and the development of allied services, drawing on both American and continental philosophies of treatment. New outpatient services led British psychiatry to encompass new arenas of mental health nursing, social work, and family involvement, and to introduce psychological and diagnostic testing alongside psychotherapeutic techniques. In 1932, Skottowe became medical superintendent at the new Swansea Mental Hospital. In 1935, with Madeline Lockwood, he reported on the outcomes of one hundred and fifty patients who had accessed treatment through the Psychiatric Out-Patient Department at Swansea General Hospital between March 1933 and October 1934. They found that “the results of mental treatment are very much better in those cases who received advice in the first instance at the Psychiatric Out-Patient Department than in the general run of mental hospital admissions.” The reason for this was not entirely clear, but the authors tentatively suggested the possibility that “problems of ‘accessibility,’ ‘insight’ and ‘rapport’ were involved.”39 Hence, the development of such approaches associated with outpatients clinics promoted the adoption of a new therapeutic vocabulary in British psychiatry. Patient aftercare was associated with the wider and more encompassing public health philosophy identified with this movement.

Social Work and Child Guidance The influence of the American mental hygiene movement was enshrined in a growing concern to intervene in the life of the patient beyond the hospital setting and provide follow-up care. In 1924 the “Cardiff Mental After-Care

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Committee” was established, comprising representatives of the Cardiff Corporation, the Board of Guardians, and the League of Social Service, with the object of providing voluntary workers to visit patients’ families prior to their leaving hospital and to offer practical help and support to patients and their families after discharge.40 Although there were long-established UK precedents, the movement that blossomed during the interwar period was directly influenced by American examples.41 In 1924 Dr. Goodall outlined a plan for a “mental hygiene service” for Wales in The Lancet, advocating a network of psychiatric services, linked through clinics and general hospitals.42 It was an imaginative feat to design a system that would fit into the existing hierarchy of health structures in Wales. The more outward looking approach embodied in outpatient clinics was associated with a widening concept of the role of psychiatric services. The American influence on psychiatry in Wales was certainly dominant in regard to children and young people. The Child Guidance Council was formed in the UK in 1927 “with the assistance of the Commonwealth Fund of America.”43 The initial aim of the council was to train psychiatrists and psychologists in child guidance and to disseminate this new psychiatric service through the training and loaning of psychiatric social workers. Commissioners of the British Board of Control acknowledged the key role played by this American institution in furthering the development of child guidance programs and recorded their “indebtedness to the Commonwealth Fund, who, through the Child Guidance Council, have lent without charge trained mental health workers for an experiment period.”44 One of the beneficiaries was Swansea, where Skottowe initiated one of the earliest child guidance clinics. He won the cooperation of the town’s medical officer of health, Dr. Tom Evans, and before starting the clinic Skottowe delivered eight lectures on mental health to local school teachers.45 He secured the loan of a qualified social worker and later a permanent appointment was made. Whilst these developments owed much to American influence and finance, this does not mean that British psychiatry fully embraced the mental hygiene movement of the United States, nor does it mean that it turned its back on the German model of psychiatry. Indeed, the two influences were closely interwoven, as outpatient clinics and occupational therapy in Britain demonstrate. Adolf Meyer complained that the mental hygiene movement in the United States was itself hampered by the continued dominance of German psychiatry as a mode of thought and influence. He ascribed the failure of the Rockefeller Institute and the School of Hygiene at Johns Hopkins University to resource the study of personality functions and psychiatry, or even to adopt the nervous system as a major topic of concern, to the “parallelistic and mind-shy attitude of our leaders trained under the influence of the German school of physiology and pathology.”46

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In Britain the German and American influences converged in rather a different way, confronting particular legal and administrative structures, which prevented any simple replication. Certain aspects of psychiatric care and scientific investigation had developed more strongly and this led British psychiatry to withstand the domination of any single school of thought or external influence, rendering it more pluralistic than any of its counterparts. Also, its wider influence during this period has perhaps been underestimated. British psychiatry was certainly not inward looking during the interwar years and whilst it took a lively interest in observing practices on the Continent as well as in America, this curiosity was reciprocated.

Study Tours During the interwar years British psychiatrists manifested a growing interest in learning from developments in other European countries. This interest crystallized in annual study tours organized by the Royal Medico-Psychological Association. Isabel Wilson recalled that the driving force behind this venture was J. R. Lord, who, as superintendent of the London County Mental Hospital, Horton, pioneered the development of a system of hospital visitors and after-care work along the lines of the New York State hospitals.47 Dr. A. E. Evans, the association’s long-serving study tour secretary, produced informative reports, which brought knowledge obtained during these tours to a wide audience and were exercises in consciousness-raising amongst British psychiatrists.48 Study groups visited France, Austria, Germany, Scandinavia, Holland, and Switzerland, and planned a visit to American in 1939.

Occupational Therapy The fourth of the continental tours, in 1932, took delegates to mental hospitals in Germany, including the Gütersloh Hospital, the University Clinic at Giessen, the Frankfurt Clinic, and the Baden State Hospital at Illenau.49 Gütersloh was often referred to as “the home of occupation therapy in Europe.” German and Dutch occupational therapy was the organizing principle upon which the therapeutic regime was based. British visitors observed “the elimination of maniacal activity from the patient’s environment.”50 At the first signs of “uncontrolled conduct” the patient would be isolated to prevent the spread of any disturbance. Visitors were impressed by the calm and orderly regulation of the wards and the sense of industry and purpose. Some of the insights brought home from these tours entered official government advice to UK mental hospitals. In 1933 the Board of Control issued a memorandum, outlining the European and American system of occupation

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therapy, and recommending it as a means of improving social behavior amongst patients and aiding rehabilitation and recovery.51 Identifying “best practice” in Europe and America led the Board of Control to evaluate British psychiatry in comparative terms. Board members noted that “in England the medical staff in mental hospitals is appreciably less than is usual in the best German and Dutch hospitals.”52 However, since much of the daily work associated with occupational therapy was carried out by the nursing staff, albeit under overall medical direction, they considered it practical to implement the system in the UK. They also judged the British system in terms of the benchmark set by American psychiatry. “We believe,” they said, “that in most respects English mental hospitals compare favourably with those of any other country, but it is a matter for regret that in one respect, occupational therapy, they continue to lag behind the best American hospitals.”53 During their annual visits to Welsh mental hospitals the commissioners actively promoted occupational therapy.

Experimenting with New Treatments The Board of Control played a crucial role in the dissemination of information regarding new treatment methods. In 1936 Isabel Wilson, as medical commissioner of the board, was dispatched abroad to study the hypoglycemic shock treatment of schizophrenia.54 Before embarking on her trip, she consulted with Dr. Pullar Strecker, who was already employing the treatment at the Royal Edinburgh Hospital. Next, she spent three weeks in Vienna, observing the daily work associated with this treatment at the University Neurological and Psychiatric Klinik, under the direction of Dr. Otto Pötzl. She visited the Münsingen Mental Hospital, in Berne, Switzerland, to see patients currently under treatment and to read the case histories of former patients. Her report outlined and appraised the essential elements of the approach to treatment. This was important because at that stage there was no work available in English “from which a student may learn details of the technique and effects of the treatment.”55 She recommended that hypoglycemic shock treatment be commenced in public mental hospitals in England and Wales, but suggested that initially it should be tried in one hospital. The problem, she perceived, was in ascertaining the duration of the apparently successful results, and urged that outcomes be monitored over five to ten years.56 In 1937 Dr. Wilson, accompanied by W. Rees Thomas, embarked on another journey to study the cardiazol treatment of schizophrenia. They visited Frankfurt, Vienna, and Budapest, where Dr. von Meduna, the originator of the cardiazol treatment, “took the trouble to demonstrate the treatment at Angyalfold hospital, to describe both his experiences with it and

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his views on the theoretical basis of the work.”57 Cardiazol treatment was taken up rapidly, not only in Europe but also in America, where the drug was marketed as Metrazol. In 1938 Dr. von Meduna provided a table of results obtained from the doctors of twenty-nine American hospitals: nearly 60 percent of acute and subacute cases treated with Metrazol showed full remissions, whereas in chronic cases only 10 percent had resulted in “full remissions.”58 In their 1938 report Thomas and Wilson stated that it was premature to publish findings of the results obtained in English and Welsh hospitals. However, they provided the example of one Welsh mental hospital (Newport, Monmouthshire), where five patients had been treated. One case had failed to improve, treatment had been abandoned in the second, and a third showed no improvement, although two cases were discharged recovered.59 The sample is indicative of the small scale of this new therapeutic intervention. The treatment was difficult to administer and never given to more than a very small percentage of cases in mental hospitals. Its attraction was that for the first time it held out some hope that a form of active medical treatment could obtain rapid results amongst a group of patients hitherto regarded as “hopeless.” By 1938 shock treatments had been employed in a total of ninety-two UK institutions. The majority of patients (over 80 percent) in England and Wales treated by these methods (3,351 completed cases in all) had received cardiazol treatment.60 How quickly did mental hospitals in Wales respond to this new challenge? Cardiazol treatment was introduced at the North Wales Counties Mental Hospital at Denbigh when a new member of staff was appointed in 1937, in part to facilitate such treatments. Ernest Schwarz was a German refugee doctor who had arrived in the UK in 1934 and had gained experience with these treatments in Edinburgh.61 In 1938 fifty cases were treated with cardiazol and in 1939 a small unit was set up for insulin shock treatment. The Cardiff City Mental Hospital experimented with insulin treatment. It had been employing somnifaine narcosis and facilities existed for other advanced methods. Nevertheless, insulin shock treatment placed a strain on resources, for the patients required very careful monitoring and this had implications for staffing. In 1938 the Board of Control commissioner recommended that owing to the “heavy demand on the time of the doctors concerned” an additional medical officer should be employed.62 In discussing insulin and cardiazol treatments the commissioners noted that a major difference between British and German or Dutch mental hospitals lay in the ratio between medical staff and patients; the British hospitals were relatively understaffed. The new shock treatments demanded skilled medical attendance and exposed the inadequate staffing in many establishments, so in Wales the asylums at Carmarthen and Talgarth never attempted to employ these more sophisticated and potentially dangerous treatments. It

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was only the introduction of the simpler and less dangerous electric shock treatments in the 1940s that, enabled them to innovate and employ these newer methods of therapy. At the Swansea City Mental Hospital Dr. Moulson had begun experimenting with cardiazol, and was at the point of holding discussions with F. L. Golla63 about the efficacy of employing insulin shock treatment, when it was announced that the hospital would be converted to a casualty hospital should war break out. Both insulin shock and cardiazol treatment plans were abandoned. However, during the war the hospital purchased an ECT (electroconvulsive therapy) machine, which Dr. Moulson rightly believed would replace other forms of shock treatment.64 Following the outbreak of war in 1939 Cardiff City Mental Hospital was once again converted to a military hospital, although it retained a limited function as a mental hospital. The period of interwar innovation and research came to an abrupt end. Writing in 1963, Isabel Wilson recalled the introduction of hypoglycemic shock treatment in mental hospitals in the 1930s. Although the high claims made for it at the time were not justified, she felt that such treatments were transformative, for they introduced a new sense of purpose and optimism into a system hitherto characterized by profound pessimism. “Insulin therapy and cardiazol made the first cracks in the black ice which held us powerless in that era,” she suggested.65 These innovations were also important in that they brought the results of experimental treatments in psychiatry into the mainstream of medical literature. Such active medical treatments required greater input from medical staff and therefore held out some hope of realigning the staff/patient ratio in public mental hospitals in the UK. This was increasingly recognized as a fundamental prerequisite for the modernization of British psychiatry, and would be one of the significant outcomes of the establishment of the National Health Service in 1948.

Interwar Research Work at Cardiff Within Wales only the Cardiff City Mental Hospital supported a team of researchers capable of investigating physiological causes of mental illness. Its research laboratory received financial support from the City Council, the Medical Research Council (MRC), and the Rockefeller Foundation, and it made a significant contribution to studies of biochemical changes in the brain. Research in this area began in a small way with the appointment of Dr. R. V. Stanford as a research chemist in 1909. He had the benefit of both practical and theoretical experience and was fluent in German, having completed a PhD at Kiel University. One of his first tasks was the painstaking work of perfecting the accurate measurement of minute chemical quantities

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required to undertake meaningful analysis of cerebrospinal fluid. The medical superintendent, Edwin Goodall, strongly believed that progress in psychiatry depended upon scientific research leading to improved understanding of chemical processes in the brain, and this made the research laboratory central to the mental hospital and encouraged international research. Scientific investigations at Cardiff were given considerable support by the Rockefeller Institute. In 1924 the MRC invited staff at Cardiff to report upon the therapeutic effects of a synthetic arsenical compound, known as Tryparsamide, being produced at the Rockefeller Institute in New York. The drug was employed for the treatment of neurosyphilis. Four cases, “in the form of dementia paralytica,” were available at the hospital, but none was of less than a year’s duration. Three of the cases showed no mental or physical improvement, and in the fourth there was physical improvement only. Detailed clinical and laboratory records were kept and a full report passed to the MRC.66 This was the first direct link between Cardiff City Mental Hospital and the Rockefeller Institute, and for the remainder of the interwar period Rockefeller funding paid for the employment of a research chemist and supported a series of discrete projects. Following Stanford’s retirement in 1929, Juda Quastel was appointed to the new position of Director of Research. The son of Jewish parents who had emigrated to the UK from eastern Galicia, Juda was born in Sheffield in 1899. He had won a scholarship to Imperial College, London, and in 1921 he entered Trinity College, Cambridge, where he worked on bacterial metabolism with Gowland Hopkins and was elected a Fellow in 1924. He did important work on the actions of enzymes and recognized the parallel and overlapping reactions between bacterial metabolites and the formation of pyruvic acid, and this led him on to do work on inhibitors to the oxidase system.67 The jump from bacterial metabolism to brain metabolism was not so great, or so he assured his interview panel at Cardiff. The post there offered the attraction of a salary of “£800 a year, dinner and teas included.”68 Quastel had been encouraged to apply by Gowland Hopkins, his mentor, and by Sir Walter Fletcher, secretary of the MRC. Fletcher was hopeful that Quastel’s appointment would enable the MRC to bring the laboratories at Cardiff more within the orbit of mainstream research. “We have long wanted to get effective work done in that particular plane,” he told Henry Hallet Dale of the National Institute for Medical Research, “and I have been hoping that Quastel’s arrival there would give quite new opportunities.”69 There were very few such biochemical laboratories anywhere in the world and little systematic work had been undertaken on brain chemistry in relation to problems of mental disorder. Quastel found that it took him “some time to become familiar with psychiatric nomenclature and with psychiatric thought, none of which was conducive to laboratory studies of the brain.”70 At that time, he observed, the majority of doctors in British mental hospitals were

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antagonistic to laboratory work. In Cardiff however, there was an established practice of holding Friday afternoon seminars in the laboratory for medical staff, when they could discuss problems arising on the wards. One issue of concern was the unpredictable reaction of patients to treatment by prolonged narcosis. Quastel therefore began to study the variable effects of the toxicity of the barbiturates employed. He visited Dr. Max Guggenheim, the director of research for Hoffmann-La Roche in Basel, Switzerland, who then provided a series of barbiturates with known clinical effects for conducting in vitro trials in Quastel’s laboratory.71 These investigations led to very productive research on various aspects of cerebral metabolism. Johnstone and Scholefield have suggested that through his “study of the action of neurotropic agents on the metabolism of brain tissue in vitro,” Quastel played a leading role in “the establishment of the science of neurochemistry.”72 In March 1934, R. A. Lambert of the Rockefeller Foundation carried out an institutional visit to Cardiff City Mental Hospital and prepared a report on the psychiatric research supported by the British MRC with funding from the Rockefeller Foundation. Lambert reported that Cardiff was “the best known of the group of insane hospitals in Wales.” He regarded the director, Professor McCowan (who had succeeded Goodall in 1929), as a “very capable administrator as well as a good clinician, keenly interested in research.” Lambert was much impressed by Quastel, whom he described as “a dynamic Jew, about 37 years old. (Wife is American). Q. is keen and enthusiastic,” he wrote, “and it is a joy to talk with him.” The research here started several years ago with a study of the action of narcotics beginning with the barbital group, much used in certain of the psychoses. Since all of these drugs produce their therapeutic effect by depressing the normal oxidative processes in the c.n.s. (central nervous system), and as their toxicity is due to a general derangement of carbohydrate metabolism, the studies have led to investigation of basic problems in brain and general metabolism.73

Quastel explained that because of the lack of knowledge of normal brain physiology, “much spade work” had to be done “before progress is possible on the pathological side.”74 Good spadework and careful attention to detail became the hallmarks of practice at the Cardiff laboratory, and in time these practices generated significant results, especially when coupled with Quastel’s gift for imaginative thinking. As Quastel’s laboratory began to gain international renown, it attracted young researchers to Cardiff. Lionel S. Penrose joined the team in 1929 “as research student, combining with this the duties of an assistant medical officer.”75 Penrose had spent two years in Vienna, where he became interested in the study of mental illness and then qualified in medicine. In Cardiff he conducted a study of schizophrenia, submitting a successful MD

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thesis on the subject in 1930 before moving to the Royal Eastern Counties Institution at Colchester in 1931, where he began his influential researches into “mentally defective” patients.76 Quastel analyzed material sent from Colchester relating to a shared interest in Folling’s disease, known as phenylpyruvic imbecility or oligophrenia. Analysis of urine samples was conducted in the laboratory at Cardiff, and it was Quastel who coined the term “phenylketonuria,” now commonly shortened to PKU.77 During the early 1930s, Quastel began hearing from scientists who were seeking positions in his laboratory that would enable them to obtain exit visas from Nazi Germany. “I could do little for them in my small laboratory,” Quastel ruefully remarked, “but I must have helped in all perhaps a dozen families to escape.”78 One of these scientists was Dr. Michael Tennenbaum. He had worked with the enzymologist Peter Rona, but in Cardiff it became apparent that he had few skills to offer in relation to the existing program of that laboratory. Therefore, his arrival led to a new strand of investigation. Tennenbaum had experience estimating acetylcholine by the leech bioassay, and so in 1935 Quastel decided to commence a line of research employing this technique. By the following year they had shown that acetylcholine was synthesized in the brain at the expense of glucose breakdown.79 Another “deposed scholar,” Dr. S. L. Last, a physiologist, was completing a year in the Cardiff Medical School in order to qualify to practice in the UK. He contributed half of his time as a voluntary research assistant in the mental hospital. He conducted a chronaxy study, “using technique learned in Lapicque’s laboratory, Paris.”80 Last was one of a number of refugees who completed their interrupted medical education at the Welsh School of Medicine in Cardiff.81 In 1938 two more refugees joined Quastel’s team: Dr. M. Michaelis and Dr. Efraim Racker.82 Racker, from Vienna, worked with Quastel on modifying existing methods of estimating histidine in urine, in order that reliable quantitative data could be obtained. It had been suggested that abnormal quantities of histidine were excreted in the urine of psychotic patients, but he found that much larger quantities could be found normally than had hitherto been recorded and therefore such quantities were not symptomatic of psychoses.83 He quickly realized that his hopes of finding biochemical causes for mental diseases were doomed, “since too little was known on the metabolism of normal cells.”84 Racker carried out a study of traumatic shock due to tissue asphyxia and blood coagulation,85 whilst Michaelis worked with Quastel on the mechanism of action of narcotics.86 By the end of the interwar period the Rockefeller Foundation was beginning to see Quastel’s work on brain chemistry as one of its more worthwhile projects. “This is one of the subjects,” wrote Dr. D. P. O’Brien, assistant director of medical sciences at the foundation, “which have been nursed along slowly but which seem to be increasing in importance in discoveries and in

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volume of work done.”87 Dr. Edward Mellanby, who had succeeded Sir Walter Fletcher as secretary of the MRC, also spoke approvingly of the research, and wrote to O’Brien: “As you know, I have a very high opinion of Quastel’s work on brain chemistry and he seems to be developing the subject very rapidly and successfully now.”88 The following year Mellanby wrote to O’Brien that “Quastel has recently received definite recognition of his excellent work in biochemistry by his election as a Fellow of the Royal Society.”89 Following the outbreak of war in 1939 the prospects for pursuing research in brain chemistry at Cardiff became increasingly bleak; the mental hospital was once more transformed for military use and the research laboratory reduced in size. In 1940 the war situation was grave, rumors of German invasion were rife. The German refugee scientists were now thought of as potential risks. As Gottfried Schatz sardonically remarked, “Racker suddenly found himself an enemy alien whose experiments with human urine near the strategically sensitive coast posed a security risk.”90 In 1940 Racker and Michaelis were “evacuated under the new Regulations applying to aliens,”91 and Tennenbaum too was interned as an alien in the Isle of Man. This dealt a serious blow to Quastel’s team. Meanwhile, overtures from Duke University School of Medicine and Yale, designed to relocate Quastel to the United States, failed to gain Rockefeller Foundation support. Ostensibly this is explained by the foundation’s political sensitivities regarding relationships with a Britain already at war. “It would be a serious mistake,” wrote Dr. Alan Gregg, director of medical sciences at the foundation, “for Dr. Quastel to allow in Britain the impression to arise that just at this time he was attracted to research in the United States, or to run the risk of his American acquaintances thinking something similar.”92 With work at Cardiff slowing down, Quastel was first transferred to Cambridge and then in 1941 moved to a post with the Agricultural Research Council, aimed at increasing soil productivity through investigations of soil metabolism. Although Quastel was offered a post at Cardiff after the war, he chose to spend the remainder of his career in Canada. For a mere decade, a crucial moment in the emergence of neurochemistry, the laboratory at Cardiff had been headed by a man regarded as “one of the greatest scientists of this era.”93 It had acquired international standing, attracting “numerous visitors from the USA and Continental Europe.”94

Conclusion This chapter has demonstrated the vibrancy of contacts between German, British, and American psychiatry as witnessed from Wales. The flow of information was not one of linear diffusion, but rather one of a more dynamic circulation; practices were adapted and modified according to different

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circumstances and institutional structures. The development of psychiatry and the movement of scientists reflected not only the development of therapeutic philosophies and medical science but also—ultimately—the political imperatives of the interwar years. Finally, this chapter has shown that Wales, a small nation within the United Kingdom, can usefully illuminate the international dynamics of interwar psychiatry.

Notes 1. Ireland was partitioned in 1922. 2. “Notes and News,” Journal of Mental Science 59 (1913): 163. 3. Ibid., 163–65. 4. “Mental Research—Cardiff and State Grants,” South Wales Daily News (30 January 1913): 303; newspaper cuttings journal kept in Whitchurch Hospital, Cardiff. 5. Ibid. 6. Hilary M. Thomas, Whitchurch Hospital 1908–1983: A Brief History to Celebrate the 75th Anniversary of the Hospital (Cardiff: Whitchurch Hospital, 1983), 20. 7. Edwin Goodall, “Notes and News,” Journal of Mental Science 59 (1913): 538. 8. “Brain Experts—A Visit to Cardiff,” South Wales Daily News, 14 August 1913. 9. Ibid. 10. Ben Shephard, “‘The Early Treatment of Mental Disorders’: R. G. Rows and Maghull, 1914–1918,” in 150 Years of British Psychiatry, Volume II: The Aftermath, eds. Hugh Freeman and German Berrios (London: Athlone, 1996), 434–64. 11. Pamela Michael, Care and Treatment of the Mentally Ill in North Wales 1800– 2000 (Cardiff: University of Wales Press, 2003). 12. Western Mail (28 January 1914): 8 13. Ibid. 14. Glamorgan County Record Office, Cardiff City Mental Hospital, D/D HWH 1/1 (hereafter GCRO, CCMH), Minutes of Visiting Mental Hospital Committee (VMHC), 31 July 1919. 15. GCRO, CCMH, Minutes of VMHC, 31 December 1920. 16. GCRO, CCMH, Minutes of VMHC, 27 September 1921. 17. National Archives/PRO, MH 96/905, letter from Lieut. Colonel E. Goodall, Medical Superintendent Cardiff City Mental Hospital, Whitchurch, Cardiff, to Sir Thomas Hughes, Chairman, Ministry of Health, City Hall, Cardiff, 15 September 1920. 18. Charles Webster, “Health and Devolution,” in Health and Society in Twentieth Century Wales, ed. Pamela Michael and Charles Webster (Cardiff: University of Wales Press, 2006), 242–45. 19. National Archives/PRO, MH 96/905, letter from Lieut. Colonel E. Goodall, Medical Superintendent Cardiff City Mental Hospital, Whitchurch, Cardiff, to Sir Thomas Hughes, Chairman, Ministry of Health, City Hall, Cardiff, 15 September 1920. 20. Michael Gelder, “Adolf Meyer and His Influence on British Psychiatry,” in 150 Years of British Psychiatry, 1841–1991, ed. German Berrios and Hugh Freeman (London: Gaskell, 1991), 419–35.

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21. Alan Trevor Jones, “The New Medical Centre and the Development of Medical Education in Wales,” Wales and Medicine, ed., in John Cule (Llandysul: Gomer, 1975), 23–9. 22. Gelder, “Adolf Meyer,” 424. 23. In considering British influences on his own development, Adolf Meyer credited Edwin Goodall as having inspired him to devote his life to clinical neurological work in part by his demonstration (at the Nottingham meeting of the British Medical Association in 1892) of cortex sections employing Bevan Lewis’s methods. See Adolf Meyer, “The Fourteenth Maudsley Lecture: British Influences in Psychiatry and Mental Hygiene,” Journal of Mental Science 79 (1933): 436. 24. Patricia Allderidge, “The Foundation of the Maudsley Hospital,” in 150 Years of British Psychiatry, 1841–1991, 79–88; Aubrey Lewis, “Edward Mapother and the Making of the Maudsley Hospital,” British Journal of Psychiatry 115 (1969): 1349–66; Edgar Jones, “Aubrey Lewis, Edward Mapother and the Maudsley,” in European Psychiatry on the Eve of War: Aubrey Lewis, the Maudsley Hospital, and the Rockefeller Foundation in the 1930s, ed. Katherine Angel, Edgar Jones, and Michael Neve, Medical History, Supplement 22 (London: The Wellcome Trust Centre for the History of Medicine at UCL, 2003), 3–38; see also Rhodri Hayward in this volume. 25. Thomas, Whitchurch Hospital, 21. 26. Isabel Hutton, Memories of a Doctor in War and Peace (London: Heinemann, 1960), 127–28. 27. Ernest Jones, Free Associations (New York: Basic Books, 1959), 166. 28. R. Andrew Paskauskas, ed., The Complete Correspondence of Sigmund Freud and Ernest Jones, 1908–1939 (Cambridge, MA: Belknap Press, 1993), xxii. 29. Ernest Jones, ed., Papers on Psycho-Analysis (London: Baillière, Tindall & Cox, 1913). 30. Dean Rapp, “The Early Discovery of Freud by the British General Educated Public, 1912–1919,” Social History of Medicine 3 (1990): 217–44. 31. Roy Porter, “Two Cheers for Psychiatry! The Social History of Mental Disorder in Twentieth Century Britain,” in 150 Years of British Psychiatry, Volume II, 389; Trevor Turner, “James Crichton-Browne and the Anti-Psychoanalysts,” in ibid., 144–55. 32. “Report of Afternoon Session, 28 July 1921,” Journal of Mental Science 33, no. 276 (1921): 105. 33. Ibid., 107. 34. Malcolm Pines, “The Development of the Psychodynamic Movement,” in 150 Years of British Psychiatry, 1841–1991, 206–31. 35. Jones, Free Associations, 161. 36. Wellcome Trust Library for the History of Medicine, The Twelfth Annual Report of the Board of Control for the Year 1925 (hereafter 12th AR of BC for 1925, and so on) (London: HMSO, 1926). 37. J. S. Ian Skottowe, “On the Methods in Vogue at the Boston Psychopathic Hospital,” British Journal of Psychiatry 74 (1928): 474–87. 38. 17th AR of BC for 1930 (London: HMSO, 1931), 127. Déjerine’s work on psychotherapy first appeared in English in 1913. Déjerine advocated the “therapeutic action of kindness,” the efficacy of “common-sense methods,” and the doctrine of “rational persuasion,” at the same time rejecting Freud’s emphasis on the sexual aetiology of neurosis. This chimed well with British psychiatry and the philosophy of

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Déjerine influenced a number of notable British psychiatrists; see Shephard, “Early Treatment.” 39. Ian Skottowe and Madeline Lockwood, “The Fate of 150 Psychiatric OutPatients,” Journal of Mental Science 81 (July 1935): 508. 40. Thomas, Whitchurch Hospital, 23. 41. Mental Treatment: Report of the Proceedings of the Conference [ . . . ] Held at the Central Hall, Westminster, 22 and 23 July, 1930 (London: HMSO, 1930), 116–22. 42. The Lancet (20 December 1924): 1273–75. 43. 25th AR of BC for 1938 (London: HMSO, 1939), 67. 44. 20th AR of BC for 1933 (London: HMSO, 1934), 3. 45. Thomas. G. Davies, A History of Cefn Coed Hospital (West Glamorgan Health Authority, 1982), 16. 46. Meyer, “Maudsley Lecture,” 458. 47. Isabel G. H. Wilson, “Travels in Psychiatry,” British Journal of Psychiatry 109 (1963): 169; John R. Lord, Mental Hospitals and the Public: The Need for Closer Co-operation (London: Adlard and Son, 1927). 48. Wilson, ibid., 169. 49. A. E. Evans, “A Tour of Some Mental Hospitals of Western Germany,” Journal of Mental Science 79 (1933): 150–66. 50. Ibid., 155. 51. Board of Control, Memorandum on Occupation Therapy for Mental Patients (London: HMSO, 1933), reference 37051, enclosure to Circular 790. 52. 19th AR of BC for 1932 (London: HMSO, 1933), 6. 53. 18th AR of BC for 1931 (London, HMSO, 1932), 9. 54. Isabel Wilson, A Study of Hypoglycaemic Shock Treatment in Schizophrenia (London: HMSO, 1936), 4. 55. Ibid., 3. 56. Ibid., 60. 57. W. Rees Thomas and Isabel Wilson, Report on Cardiazol Treatment and on the Present Application of Hypoglycaemic Shock Treatment in Schizophrenia (London: HMSO, 1938), 3. 58. Ibid., 50–51. 59. Ibid., 54. 60. 25th AR of BC for 1938 (London: HMSO, 1939), 36–8. 61. Michael, Care and Treatment, 133, 141. 62. 24th AR of BC for 1937 (London: HMSO, 1938), 462. 63. After some years at the Maudsley Hospital, in 1937 Golla was appointed Professor of Mental Pathology at the University of London; see J. M. Bird, “The Father of Psychophysiology: Professor F. L. Golla and the Burden Neurological Institute,” in 150 Years of British Psychiatry, Volume II, 509. 64. Davies, Cefn Coed Hospital, 24–26. 65. Wilson, “Travels,” 173. 66. 11th AR of BC for 1924 (London: HMSO, 1925), “Report from Cardiff City Mental Hospital,” 120. 67. F. C. MacIntosh and T. L. Sourkes, “Juda Hirsch Quastel, 2 October 1899– 15 October 1987,” in Biographical Memoirs of Fellows of the Royal Society 36 (December 1990): 387.

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68. Juda Hirsch Quastel, “A Short Autobiography,” in A History of Biochemistry, Comprehensive Biochemistry 35, ed. A. Neuberger and L. L. M. Van Deenen (Amsterdam: Elsevier Science Publications, 1983), 151. 69. National Archives/PRO FD/2109 CSF Cardiff, Sir Walter Fletcher to H. H. Dale, 18 December 1929. 70. Quastel, “A Short Autobiography,” 155. 71. Ibid., 159. 72. R. M. Johnstone and P. G. Scholefield, “Professor J. H. Quastel, F.R.S., F.R.S.C.,” Canadian Journal of Biochemistry 13, no. 7 (1965): 4. 73. “Psychiatric Research in Cardiff Mental Hospital, Supported by the BMRC,” Memorandum R. A. Lambert to Alan Gregg, March 27, 1934, Rockefeller Archive Center, Rockefeller Foundation, Record Group 1.1 (hereafter RAC, RF, RG), folder 1, box 1, sub-series A, series 407 (Wales). 74. Ibid. 75. 16th AR of BC for 1929 (London: HMSO, 1925), app. B, 292. 76. A. M. Cook, “Penrose, Lionel Sharples (1898–1972),” in Oxford Dictionary of National Biography, ed. H. C. G. Matthew and Brain Harrison, rev. ed. (Oxford: Oxford University Press, 2004). 77. Quastel, “Autobiography,” 163–64. 78. MacIntosh and Sourkes, “Quastel,” 395. 79. Ibid. 80. Ibid. 81. Paul J. Weindling, “Medical Refugees in Wales,” in Health and Society in Twentieth Century Wales, 183–200. 82. CCMH, AR for the year 1938, Report of the Medical Superintendent (hereafter MS), 23; Gottfried Schatz, “Efraim Racker,” Biographical Memoirs National Academy of Sciences 70 (1996): 323–4. 83. CCMH, AR for the year 1938, Report of MS, 20; CCMH, AR for the year 1939, Report of MS (30 June 1940), 17; Efraim Racker, “Histidine Estimation and Excretion in Cases of Mental Disorder,” Biochemistry Journal 34 (1940): 89. 84. Schatz, “Racker,” 324. 85. CCMH, AR for the year 1939, Report of MS (30 June 1940), 18. 86. M. Michaelis and J. Quastel, “Mode of Action of Narcotics on Tissue Respiration Processes,” Biochemistry Journal 34 (1940). CCMH, AR for the year 1939, Report of the MS (30 June 1940), 17. 87. Extract from letter of Dr. P. O’Brien, 10 February 1939, RAC, RF, RG 6.1, Paris Field Office, folder 3, box 8, series 1.1 (prewar correspondence). 88. Ibid., Mellanby to O’Brien, 14 February 1939. 89. Ibid., Mellanby to O’Brien, 29 March 1940. 90. Schatz, “Racker,” 324. 91. CCMH, AR for the year 1939, Report of MS (30 June 1940), 21. 92. Alan Gregg to Mrs. Quastel, 25 July 1940, RAC, RF, RG 1.1, folder 1, box 1, series 407, sub-series 19. 93. K. A. C. Elliott, “My Colleague Q,” Canadian Journal of Biochemistry 13, no. 7 (1965): 7. 94. Quastel, “Autobiography.”

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Chapter Eleven

Alien Psychiatrists The British Assimilation of Psychiatric Refugees, 1930–1950 Paul J. Weindling Between 1930 and the immediate postwar years, approximately 5,200 medical refugees (defined as including persons in all health care occupations) came to, or through, Great Britain as a result of National Socialism and the Second World War.1 Psychiatrists and psychoanalysts were two of the most innovative groups of medical refugees. They transformed Britain from a receiving center of pioneering continental approaches to a major international center of psychiatry and psychoanalysis.2 The refugee influx came on top of intensifying international interchanges in psychiatry and psychoanalysis, as Britain opened up to both American and Central European influences. Psychiatry and psychoanalysis were becoming part of mainstream scientific medicine internationally. Their aims were the active treatment and prevention of anxiety states, neuroses, and psychoses. Psychiatrists saw these mental disorders as no different from any other illness, and psychotherapy was increasingly accepted by mainstream medicine.

Transferring Skills The refugees can be seen as agents of transfer of Central European models of classification, etiology, and therapy. In psychoanalysis the transfer of personnel, concepts, and practices from the major centers of Vienna, Berlin, and Budapest to London signified the establishment of a new center of research for this discipline—and also the intensification of previously existing, long-term tranfers from Central Europe. The Austrianborn Melanie Klein established herself in London in 1926, where she developed her ideas of child analysis and received support from Ernest Jones, the key organizer of psychoanalysis in Britain. We therefore find

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that prior internationalization of psychoanalysis had already shaped structural divisions in the receiving community of London with the rift between Freudians and Kleinians. In psychiatry the Kraepelin school in Munich played a key role in the transfer of psychiatric models, since it had been well received at the Maudsley Hospital in London. Here, we have a primary transfer from Germany to the United Kingdom. Yet continental influences on the UK were many and varied. The quality of the arriving theories was complex, because of the sheer pluralism in different styles of psychiatry. There was a spectrum of scientific approaches to organic mental illness and psychosexual problems. Some highly unorthodox figures, such as the Austrians Karl König (1902–66) and Joshua Bierer (1901–84), achieved considerable success. Less successful were the biologically based sexologists. The left-wing Berlin sexologist Max Hodann (1894–1946) failed in his attempt to establish an institute for sex research in Britain and eventually moved to Sweden.3 There were, however, notable pockets of support for the unconventional: Aldous and then Julian Huxley helped the Berlin psychiatrist and chirologist (handreading as a means of gauging character, temperament, intelligence, and mental functioning) Charlotte Wolff (1897–1986). Julian Huxley, as secretary of the Zoological Society, supported her comparisons of ape and human palms at the London Zoo.4 Britain’s role, however, was only as a temporary refuge, and in the case of the Freudians, after a final solidarity around the dying Sigmund Freud (1856–1939) in London, the retinue moved westward. North America was very much a presence in the psychiatric transfers, exerting a pull on the medical refugees. The high scientific credentials of the Kraepelin school meant that a select number of neurohistologists also moved westward to North America. Karl Stern (1906–75) came from the German Research Institute for Psychiatry to Queen Square, and after a few years moved to Montreal, Canada, where his outlook was wholly transformed.5 At the same time, the Swiss expatriate Adolf Meyer (who had already adapted German psychiatry to a more subjective empathy with the patient), now at Johns Hopkins in Baltimore, exercised a positive influence on mental health in the UK, and especially in Scotland.6 Meyer was interested in all the biological, psychological, and social factors in patients as well as patients’ perceptions. It meant that certain key innovators in the UK, such as the Edinburgh psychiatrist David Henderson, and Douglas MacCalman in Glasgow, were responsive to émigrés. American foundations exerted a positive force on British psychiatry. The Rockefeller Foundation took the view that research should lead to an understanding of mental illness as a treatable disease, so that psychiatric provision needed to be brought into mainstream medicine. The Rockefeller Foundation supported the development of specialist psychiatric units in major

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general hospitals, as well as brain and psychiatric research. From 1928 the Commonwealth Fund backed mental hygiene and child guidance services, providing an opportunity for refugees to take positions in community-based experimental programs in the treatment of mental health problems.7 Britain served three functions for the refugee mental health specialists. For a very small number, it was a country of exile, and they returned to Germany and Austria after the war. It was rare for psychiatrists or analysts to be among those who returned. For a second significant group, Britain was a temporary refuge from persecution, but they looked to other countries, notably the United States, for eventual settlement. Many Freudians moved rapidly to the United States spurred by Freud’s death on 23 September 1939, the unsure fate of Britain at war, and a sense that professional opportunities were poor in Britain. However, the experience of waiting for an uncertain American visa could be “sterile” and “heartbreaking.”8 The majority of psychiatric refugees thus weathered the storms of professional exclusion and the stigma of being an enemy alien. Most eventually found Britain a congenial and receptive place for psychiatrists. These refugee psychiatrists and psychotherapists were representatives of disciplines that belonged to the most innovative and successful medical specialties. They have necessarily separate histories, which intersect occasionally because psychoanalysts in Austria and Germany were generally medically qualified. The German-model of medical specialization was science-based, and in Britain there was concern about competition with highly qualified continental specialists, prompting a tightening of supervisory regulations by the British Medical Association (BMA) in the 1930s.9 Psychiatry represented a broad spectrum of theory and practice; the Kraepelin school of scientific psychiatry was concerned with classification and causes of illnesses (schizophrenia is the classic example), whereas others were interested in therapeutics, such as insulin shock therapy and neurosurgery. German scientific models and Austrian psychoanalysis presented two significant poles of the spectrum. There were as well diverse strands of psychoanalytical approaches, Freudian, Kleinian, Jungian, and Adlerian “individual analysis” being the most notable. Some psychoanalysts were clinically detached, while others, such as Michael Balint (born Mihály Maurice Bergmann, 1896– 1970), offered patient-oriented approaches., The refugees came from many different countries, including Germany, Austria, Czechoslovakia, Hungary, Poland, and Italy. Studies of refugee psychoanalysts and psychiatrists have been either limited to biographies of notables, such as Anna Freud, or have been impressionistic essays, exploring themes rather than life histories.10 This paper is based on a “total-population” approach to medical refugees in general, and involves reconstructing, as far as possible, the histories of all psychiatrists. This inclusive approach has several advantages: It encompasses a broad

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spectrum of therapeutic styles and allegiances. It recognizes that psychiatry was practiced in a variety of contexts ranging from specialist hospitals to the surgeries of general practitioners It confirms that, compared to more prestigious medical specialties such as obstetrics and surgery, which absorbed few refugees, British psychiatry was relatively open to refugees. It corrects the prevailing bias of a focus only on cases of outstanding professional and scientific success. Some refugees found themselves in marginal positions, and others became depressed, ill, and suicidal.

Psychiatry British psychiatry was able to absorb relatively large numbers of medical refugees. This was because of enlightened and far-sighted reformers—notably the innovators Frederick L. Golla and Aubrey Lewis (who experienced exclusion as a Jew in his native Australia)—at the Maudsley Hospital.11 They were aware that specialist training in psychiatry was very limited. Training institutions like the Maudsley Hospital and the Tavistock Clinic welcomed the influx of continental experts in part to remedy the defects in British psychiatric education. Beyond innovative therapeutic approaches, the refugees were able to transplant agendas relating to the social provision and forms of psychiatry. Between the 1930s and 1960s, as British psychiatry was modernized from the custodial care model (in large Victorian institutions, often in remote locations) to social and therapeutic psychiatry, medical refugees made a substantial and diverse contribution to the discipline. Their contributions included: drug development, innovative forms of psychotherapy, institutional reform with community-based provision, child guidance, and improved diagnosis and understanding of the etiology of clinical conditions with human genetics. One of the aims of the refugees was that mental illness should be treated as no different than any other form of illness. During the 1920s and 1930s British psychiatric reformers had taken a keen interest in continental developments. British doctors (such as the neuropsychiatrist Derek Richter and the psychiatrist and eugenicist Eliot Slater) studied in Munich and saw the potential of biochemical and genetic approaches. Some biochemists, such as Juda Quastel in Cardiff (see the chapter by Pamela Michael), employed refugee brain researchers with funds from the Medical Research Council and the Rockefeller Foundation. There were innovative schemes, such as the East London Child Guidance Clinic of Emanuel Miller, conducted under the auspices of the Jewish Health Organisation. Alfred Adler (1870–1937) came from Austria to lecture in the clinic in 1936. This was where the German psychiatrist Paul Plaut (1894–1960) found a niche for some time.12

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Internment represented a moment of considerable crisis, when many refugees lost their clinical posts in Britain. From late 1940 the positions began to open up again. Psychiatrists benefited, as the Temporary Registration Order of 1 January 1941 for foreign medical practitioners related to any institution under the Mental Treatment Act of 1930, as well as to all institutions covered by the Mental Deficiency Act. Then, in 1942 the Ministry of Health began to plan an expansion of the country’s psychiatric resources, while at the end of 1942 the Beveridge Report called for comprehensive and free medical services for all citizens.13 The dynamic was for a massive expansion in mental health services, and here the refugee specialists were well placed. The Pioneer Health Centre—also known as the Peckham Experiment— advanced holistic medicine on a community basis. This center attracted a number of medical refugees, notably the Heidelberg-trained psychiatrist and pediatrician Anni Noll (1900–1966). At Peckham, much was made of the discovery of “hypotonia,” which was characterized as a state of “general devitalization,” even when there was no visible sign of ill health. Hypotonia was linked to sexual frigidity and a disinclination to have children. In September 1941 Noll pointed out that since four-fifths of the population had anemia that went undiagnosed, one had to speak of “normal unhealthy individuals.” She urged that emotional needs be recognized in postwar reconstruction by providing family health centers.14 British psychoanalysts had established links to Freud in Vienna, and had done much translation and dissemination of psychoanalytic theory. Ernest Jones was among those who laid classic Freudian foundations for psychotherapy in Britain. Psychoanalysis was primarily a niche for the affluent, but the Tavistock Clinic pioneered more accessible outpatient provision from 1920.15 Freud, who was one of the oldest of the medical refugees, established himself and his family in London in June 1938, signalling that this city should become a major center of psychoanalysis.16 Melanie Klein’s arrival in London from Berlin in 1926 had already strengthened the idea of this city as an international center of psychoanalysis. Ernest Jones and John Rickman encouraged analysts to come to Britain, although Jones was a willing participant in the medical establishment’s effort to push émigrés to the provinces. In this case the motivation appears to have been twofold: to expand the empire of psychoanalysis beyond London, and at the same time to avoid competition with London analysts.17 By 1938 one-third of the British Psychoanalytic Society was Viennese. Mühlleitner and Reichmayr identify twenty-three out of fifty-five émigrés from the Vienna school as residing in Britain in 1938–39, although many moved on after Freud’s death.18 Kohon estimated that there were thirtysix refugee analysts in the UK, and the database of medical refugees has also identified thirty-six non-medically qualified psychoanalysts.19 There were refugee analysts who were not admitted to the Psychoanalytic Society,

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because of the insistence on specific training requirements or adherence to classic Freudian theory. The medically qualified drew on psychoanalysis in their clinical practice, and here Balint was to reshape doctor-patient relations more generally. Refugees did much to develop British pharmacology and neurology, and certain treatments had implications for psychiatry. Again, there was an active British interest in new therapies. From the mid-1930s, the Board of Control (the state regulatory body for ensuring quality of patient care in psychiatric hospitals) was interested in deploying therapeutic innovations pioneered on the Continent. These innovations would modernize British psychiatric hospitals. The development of insulin shock therapy by Gertrude May-Gross occurred after the Board of Control had already cleared the way for humansubject trials for this therapy. Yvonne Kapp (the administrator of the Central Office of Refugees’ Medical Department from 1938) and her colleague Margaret Mynatt point out how refugees were appointed to pioneer research into treatments such as insulin shock therapy for “schizophrenia.”20 Willy Mayer-Gross (1889–1961) developed an “insulin unit” for the treatment of schizophrenia at the Maudsley Hospital.21 Cardiazol therapy for schizophrenia appeared hopeful, and the Board of Control sent representatives to Frankfurt, Vienna, and Budapest in 1937.22 Ernst Schwarz (Simmons) was appointed at Denbigh in North Wales to strengthen the scientific orientation of the hospital, and in the 1940s he selected patients for lobotomies, favoring the operation for Parkinsonism.23 Set against the reformist impulses in British medicine of the 1930s was the dead weight of tradition in mainstream psychiatry. The situation in psychiatry was very much a legacy of Poor Law provision and the continued use of Victorian institutions, which were more for containment of the mentally disturbed than for therapy. This disinclination to reform was linked to a view among rank-and-file doctors that scientific innovations held little for the seasoned clinician. Above all, an influx of foreign doctors had to be resisted as an economic threat. Academic modernizers at the Medical Research Council, the Royal Society, and universities provided the stimulus for breaking down the formal restrictionism of the BMA. They drew on the resources of American foundations, which supported the idea of funding research-oriented professors of medicine in order to raise professional standards. The Commonwealth Fund provided the initial support for Mayer-Gross to come to the Maudsley Hospital, and the Rockefeller Foundation funded his position in 1934–35.24 The next step was to give him a senior post to allow him to have an input in modernizing patient care in a major psychiatric hospital. The Rockefeller Foundation was notably ungenerous when it came to funding medical refugees, and William Beveridge was disappointed in his scheme for large-scale assistance, as the Foundation remained fixated on rules that only former

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grantees should be assisted. Foundation trustees appeared isolationist in their responses to the European crisis. However, the foundation’s visionary program officer, Alan Gregg, personally provided funding for refugee psychiatrists.25 Golla and Mapother, the Maudsley director, argued that there were no good neuropathologists in England. Rockefeller beneficiaries at the Maudsley in 1934 included Erich Guttmann (1896–1948), who joined forces with Mayer-Gross in studies of apraxia and agnosia for research into the psychopathology of brains of “mental defectives,” and Alfred Meyer. Guttmann later moved to Mill Hill Emergency Hospital.26 In September 1939 the Foundation made available funds to employ Felix Plaut (1877–1940) at Horton Mental Hospital for research on neurosyphilis.27 While innovative groups of medical reformers and scientists favored the admission of refugees, the attitude of the rank-and-file of the medical profession and its organizations was still highly restrictive. The Aliens Committee of the BMA provides telling material concerning the position of refugee psychiatrists. BMA policy was to restrict the number of refugees entering Britain; it imposed, for example, a quota of fifty Austrian doctors and forty dental surgeons in 1938, and a quota of fifty Czech doctors in 1939. Its position was that those “alien doctors” admitted “should not be allowed to settle in London.” The initial hope that after requalification doctors might be exported to the Dominions turned out to be unrealistic. The BMA consequently wanted the aliens in assistant and temporary positions in the provinces to make up shortages in war but not to take practitioners’ positions. The BMA lobbied the Home Office, opposing naturalization and any possibility of permanency.28 The idea was that the refugees should return to their home countries after the war, although this ignored the reality of displacement among many of the Jewish refugees. Many refugees experienced severe difficulties integrating into British medical circles. For example, the Munich psychiatrist Max Isserlin (1879– 1941) was unable to practice in Britain between his arrival in 1938 and his death in 1941.29 Both the neurologist Plaut and the psychoanalyst Wilhelm Stekel (1868–1940), who emigrated from Vienna but was a Romanian citizen, committed suicide in 1940. Stekel’s situation had been bleak: He suffered from physical illness that was exacerbated by his refugee status, his wife was interned on the Isle of Man, and France (where his son remained) had signed an armistice with Germany, thus putting his son’s life in danger.30 Alice Balint’s (1898–1939) death in 1939 has been interpreted as induced by migration-related deprivation.31 Other medical refugees came to Britain as domestic servants and were simply interned (Stengel, Post, and Berkenau). The years 1940–41 were a time of crisis for the refugees who were dismissed from hospital positions due to the post–Dunkirk invasion scare. The year 1941 culminated in the internment of many German practitioners, such as, albeit briefly, the well-connected Felix Post (1913–2001), and there was a

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risk of internment for all German practitioners. This crisis situation, and the death of Freud in 1939, prompted a spate of remigrations onward to North America, such as that of the Jungian James Kirsch to Los Angeles, and the Freudians Ernst (1900–1957) and Marianne Kris (1900–1980) to New York. On the other hand, the war exposed deficiencies in psychiatric provision in the UK, and refugees readily contributed their efforts to the care of evacuees, to military psychiatry, and to the treatment of casualties.32

Psychoanalysis During the war years London was emerging as the international center of psychoanalysis, not least because of the Nazi onslaught against psychoanalysis as a Jewish science. The factious disputes between Freudians, Kleinians, and Jungians generated a rich palette of therapeutic ideas, and the influx of refugee analysts added to the creativity in therapeutic circles. A particular point of friction was the permissive policy toward psychoanalysis in Britain. Britain (uniquely) permitted lay analysis by a practitioner who did not hold medical qualifications. Whereas in Germany and the United States most psychoanalysts were physicians, this was decidedly not the case in Britain, which made it attractive to some psychoanalysts. The support of refugee physicians by British psychoanalysts meant that the Home Office was prepared to allow refugee doctors to practice as lay therapists. But the BMA insisted that refugee physicians settle in the provinces. This enforced marginalization undermined the feasibility of making an income as an analyst. Erwin Stengel (1902–73) came to Britain in 1938 from the Wagner-Jauregg Clinic in Vienna with the aid of Ernest Jones of the British Psychoanalytical Society. Writing from Wells in Somerset in January 1939, Stengel observed that “the possibilities of earning one[‘]s livelihood by psychotherapy in a provincial city are very limited, especially for a new-comer.”33 Stengel’s dilemma was that the Bristol Mental Hospital offered him a post; however, the position was not in private practice, which was the very basis of his admission to Britain. The solution was to appoint Stengel as a research assistant, but others were not so fortunate. The BMA attempted to close the back door of psychotherapy as a route into British medicine. But thanks to the vigor of the Tavistock Clinic in its advancement of mental hygiene and the psychoanalysis of the emotions, and to supporters of psychoanalysis like Ernest Jones (who was Home Office adviser) and J. R. Rees, the medical director of the Tavistock, the protected status of the lay psychotherapists was sustained. The BMA attacked this status in August 1940: “Resolved: that the Home Office be informed that the [Home Office Medical Advisory] Committee is strongly opposed to the employment of alien medical practitioners as lay psychotherapists.”34

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As director of the army’s psychiatric services and, as a Colonel, Rees managed to secure a guarantee that the Home Office would not revoke the permits already issued. The BMA, however, continued to see the lay status of these “temporarily registered psychotherapists” as a loophole for refugee doctors whose qualifications were not recognized: The question is whether an alien could secure temporary registration in the Medical Register by reason of his selection for this form of employment. The doctor who makes the inquiry points out that the relation between himself and the alien “assistant” would not be comparable to that of a principal and an assistant in general practice, since the peculiar relationship between doctor and patient in psychological practice makes the intrusion of a third party in the form of a supervising “principal” impossible.35

For a combination of academic, professional, and sociocultural reasons, the stance of the BMA was negative and narrow. In 1942–43, the BMA resisted requests from alien analysts to move from the provinces to London. The BMA even took exception to the “report that Dr. Michael Balint, a temporarily registered Hungarian practitioner, has reported that he has been appointed Honorary Consulting Psychiatrist to the Manchester Northern Hospital.” The Home Office response was that “the position is that Dr. Balint was granted permission to land in this country in Jan. 1939 for the purpose of establishing himself in practice as a psycho-analyst in Manchester following representations which were made by the Institute of Psycho-Analysis . . . but [he] holds an Aliens War Service Dept open service permit.”36 Balint’s appointment was therefore sustained despite BMA opposition. Even so, Balint thought Manchester a cultureless and soul-destroying city, and was relieved in the more permissive postwar situation to move to London.37 On 17 February 1943, the BMA opposed the application of another innovator—the Austrian Joshua Bierer. The Home Office Medical Advisory Committee resolved: “That the Ministry of Health be informed that the Committee is of the opinion that the application of Dr. Bierer for permission to open a private home for neurotic patients should be refused, and that it be suggested that if he wishes to treat his patients by group psychotherapy he should accommodate them in a nursing home not his own.”38 The London Clinic of Psychoanalysis pointed out that the Home Office allowed private practice in psychoanalysis—as necessary for clinic appointees to make a living. Complaining that the Home Office now refused to recognize private practice, it insisted that “analytical psychotherapists do not work in competition with any other form of psychotherapy. Either the demand for psychoanalysis is supplied or it is not.”39 Bierer, who had trained in Vienna under Adler, had the distinction of being the first psychotherapist appointed to a public hospital. He served in the newly opened Runwell Hospital in Essex during 1938–42. Bierer had

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a prophetic sense of the importance of therapeutic organization, and saw that the day clinic could one day supplant the psychiatric hospital. His case was symptomatic of the increasing social importance of analysis at a time of major social upheavals caused by war.40 Anna Freud’s (1895–1982) Hampstead War Nurseries, opened in 1941, was modelled (as Edward Timms has shown) on the Jackson Kinderkrippe begun in Vienna in 1937 (even the cots emigrated to London).41 Anna Freud stresses such continuities in her Psycho-analytic Treatment of Children. The Hampstead Nurseries catered to children of bombed-out families and children whose mothers were carrying out war work.42 Anna Freud’s associate, Kate Friedlander (Friedlaender) (1902–49), went on to develop schemes for child guidance services in rural areas, and the nurseries became a noted, and rigorous, training center for analysts.43 The nurseries benefited from wide-ranging American support. Ernst Kris (1900–1957) observed that the sources of funding were stronger in areas of pro-British sentiment (e.g., Vermont) than in Wisconsin.44 The twenty trainees included Joanna Kohler (later Beekekenhof), Lizzy Wallentin (later Rolnick), Sara Kut (later Rosenfeld), Hanna Engl (later Kennedy), Alice Goldberger, and Anneliese Schurmann. Sophie Dann, a nurse who was among Freud’s medical retinue, took charge of the baby department, and her sister Gertrud took charge of the toddlers.45 Hedy Schwarz taught Montessori methods, Ilse Hellman taught mental development and testing. The nursery was an innovative center, a pioneer in parent-child relationships and in understanding the need to be mothered. Anna Freud enriched British nursery education with her theories of the mother figure in early psychological development. She lectured in 1941 to the Nursery Schools Association on “The Need of the Small Child to be Mothered.” Waking, sleeping, and play patterns were carefully analyzed to show the disadvantage of an institutionalized upbringing.46 Anna Freud developed an understanding of infantile neuroses on the basis of her Hampstead clinical observations. Anna Feud educated herself to maintain her father’s legacy and sustain the international Freudian network in its Maresfield Gardens hub. At the same time, child guidance services—already supported by the Commonwealth Fund—were enriched by training schemes for practitioners. Here, Friedlander took a crucial role through her work in the West Sussex Child Guidance Service and the East London Child Guidance Clinic.47 While psychoanalysis remained introverted in its concerns, and was characterized by internecine relationships, we see nonetheless processes of dissemination, so that Freudian ideas of psychoanalysts such as John Bowlby, of the Child Guidance Clinic, contributed to emerging orthodoxies on maternal deprivation. The dispute between Freudians and Kleinians over what Klein saw as the primitive emotions in young children resulted in the split allegiances of Ernest Jones.48 The feuding, however, helped to integrate the

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incoming refugee analysts with those in the UK, as the fissures were over theory and technique and cut across any divide between refugee and settled practitioner. The disputes on the Training Committee of the British Psychoanalytical Society lasted until 1944. The Kleinians became an influential group within British psychoanalysis.49 Adlerian psychology found a base in child guidance clinics, as had originally been the case in Vienna. Franz Plewa, formerly Adler’s assistant in Vienna, ran a clinic at Kennington in London, Mrs Nagelschmidt ran a clinic in Manchester, and Dr. Hamburger ran a clinic at Friends House, Euston Square. Lydia Sicher (1890–1962) arrived in London in 1938 after having been Adler’s successor at his Vienna clinic, although she moved to the United States in 1939.50 Jungians, as might be expected, were fewer in number. In 1944 they founded the Society of Analytical Psychology, whose members included Gerhard Adler (born 1904) and Leopold Stein (1893– 1969). In 1953 Plewa became chief of the welfare and counselling services in Boystown, Nebraska. The pressures on refugees to take assistantships in the provinces provided London clinics with significant opportunities for innovation: At a time of mass child evacuation, the enforced provincialization of psychoanalysts meant that there was a shortage of trained personnel in London. Confronted by a deluge of disturbed cases, Anna Freud and other analysts devised innovative forms of therapy and accessible care in clinics. They reinforced and strengthened the dynamic development of child guidance practices that had existed since the early 1930s. There were innovative clusters of child guidance clinics outside of London that attracted refugees. One such clinic was located deep in the English provinces, at Exeter, under Roy N. Craig. In 1941 both Michael Foulkes (Siegfried Fuchs) (1898–1976) and Stengel were employed there, and later the Czech Julius Stein moved from the stresses of the County Mental Hospital at Prestwich, near Manchester, to work as a psychotherapist at the Exeter clinic.51 It was at Exeter that Foulkes first developed group analysis. The second arena for psychotherapy was provided by the army. Foulkes’ approach was supported in a military context by Wilfred Bion at the Northfield Military Neurosis Centre.52 Bierer was also drawn into the army for two years, and then went on to develop the Social Psychotherapy Centre in Hampstead in 1946. His associate was the Adlerian analyst Emerich Weissmann (born 1904). Another arena of innovation and observation was the Crichton Royal Asylum in Dumfries, which employed, remarkably, William (he had changed his name from Willy) Mayer-Gross from 1939 until 1955, and Stengel. MayerGross collaborated with psychiatrists of a younger generation, notably Martin Roth (1917–2006), who was Hungarian-born but not a refugee. There were no other refugee psychiatrists in Scotland, although many had taken exams at Glasgow or Edinburgh.

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Despite the straitjacket that the BMA attempted to impose, the refugees found British psychiatry in a dynamic state. Most of those who endured the war years then remained in Britain. There were no returnees to Austria, just a couple to Germany or to Eastern Europe; the psychoanalyst Ernst Freud (born 1914, originally Halberstadt), a grandson of Sigmund Freud, eventually returned to Germany, and Mayer-Gross planned to return after retirement in his seventies. A small number acquired further qualifications and training in Britain, and moved on to Canada or the United States in the 1950s. Erich Wittkower (1899–1983), who in the 1930s and 1940s had links with the Tavistock Clinic and the Maudsley Hospital, moved to Montreal to develop psychosomatic medicine.

Into the Mainstream The German system of academic psychiatry linked university posts to large psychiatric hospitals, but things were initially very different in Britain. Thus Mayer-Gross gravitated toward Birmingham as an academic center, but there was no chair of psychiatry to be had there. The vibrant Stengel, who was twelve years younger, attained academic posts in London, and then the chair of psychiatry at Sheffield University, so attaining mainstream recognition.53 The contributions by Polish-trained psychiatrists were substantial. The Poles tended to work more in mainstream psychiatry (unlike the more psychoanalytically engaged Hungarian émigrés), and many Polish psychiatrists opted for posts in the provinces. The postwar period saw a shortage of specialists. Thus when Paul Berkenau (1890–1963), who obtained a medical degree from Kiel in 1920, was due to retire from the Warneford and Park Hospitals in Oxford in 1955, he was retained as locum tenens. As the hospitals’ management committee found, it was “difficult to replace Dr. Berkenau because of the small number of psychiatrists with the requisite special experience of psychoneurosis, as well as the general psychiatric background, which is required.”54 The National Health Service changed psychiatry during the 1950s and 1960s by ending the tradition of hiring medical superintendents and replacing those positions with new consultant posts and a training infrastructure.55 From the late 1950s there were efforts in psychiatry to improve the quality of facilities and of personnel. By 1956, twenty day hospitals were established in Britain. In 1958 priorities switched from mental hospitals to mental deficiency institutions and child guidance services. By the late 1950s efforts began to reconstruct British psychiatry; mental health nursing, psychiatric social work, and clinical psychology pointed the way to a community-based system of health care. Refugees took posts as psychologists in the social services. The doyen was Hans Eysenck (1916–97), who assumed, controversially, the mantle

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of Cyril Burtt in psychology while taking an iconoclastic view against Freud and psychoanalysis.56 Eysenck conducted research on personality types with Hilde Himmelweit (1918–89, later professor of psychology at the London School of Economics), at the Mill Hill Emergency Hospital in 1943; the research was supported by a Rockefeller grant through the Maudsley Hospital. The refugees played an important role in the major overhaul of British psychiatric provision. First, they served as rank-and-file clinicians. Former refugees found their skills to be of value in the reformed clinical structure. A Viennese student who had benefited from having Freud and Adler as teachers, but who was a dedicated clinician rather than an academic star, provides a telling example of the difficulties faced by medical refugees. Stefanie Felsenburg (1902–77) had studied with both Freud and Adler, yet she worked as a domestic for three years. After her degree was recognized in 1941, she worked in provincial Staffordshire, and after the war with the Jewish Board of Guardians in London. She finally joined the large suburban psychiatric hospital of Colney Hatch (later Friern Hospital) in 1950, where she worked until 1968.57 Things were far easier for the younger generation. Sabine Strich (born 1925) went “straight up the academic ladder” after graduation from Oxford to a readership at London University and a consultant’s post.58 Not only were refugees attracted to psychiatry, they also forged careers in related disciplines or they established the principles and practices of an integrated, multidisciplinary psychiatric practice. For example, Lisbeth Berndt-Guttfeld (born 1891) came from dermatology but, like other medical refugees, gravitated to socially significant fields, notably to child guidance services. By the 1960s several had posts as consultant psychiatrists in child guidance clinics. Psychogeriatrics followed, pioneered by Felix Post (1913– 2001) at the Maudsley Hospital. Post had left Germany as a medical student in July 1933, “legally and as I then thought temporarily.” He trained in psychiatry at the Maudsley, and published his seminal Mental Breakdown in Old Age in 1951.59 His legacy was continued by Tom Arie, who came to Britain as a six-year-old refugee. Combining psychiatric and other forms of medical care, Arie pioneered psychogeriatrics as the “Nottingham model” through the many students that he trained at Nottingham University.60 Former refugees played a crucial role in the restructuring of British mental health care. Rudolf Freudenberg (1908–83), who came to Britain in the 1930s as an expert in insulin coma therapy, moved from a large psychiatric hospital at Netherne to a post in the Ministry of Health, where he did much to engineer the transition to community care. The Rockefeller Foundation supported the neurosurgeon Ernst Levin (1887–1975) at Edinburgh.61 The youthful Ronald D. Laing benefited from his encounter in Glasgow with the widely read, Austrian émigré neurosurgeon Joseph Schorstein (1909–76). Ida

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Macalpine (1899–1974) and her son Richard Hunter (1923–81) achieved much as practicing psychiatrists at Friern Hospital while developing a broader historical perspective for British psychiatry.62 Others found opportunities outside conventional medicine. The anthroposophist and pediatrician Karl Richard König (1902–66) arrived in Britain in December 1938, and in 1940 (in the midst of the internment crisis) moved into Camphill House near Aberdeen, the nucleus of the Camphill village settlements for mentally handicapped children. Here, the support of the Macmillan publishing family was crucial. Although he gave up medical studies at St. Andrew’s, his community for mentally handicapped children was an outstanding success. Thus by 1950, the Camphill Rudolf Steiner Schools occupied five comparatively large estates in the surroundings of Aberdeen, where nearly two hundred fifty children were cared for by well over one hundred staff members.63 Nursing in the 1930s was in demand as a profession because of personnel shortages, and it provided a way for refugees to enter the British labor market. Consequently, the refugees raised the standards of practice in psychiatric nursing. Annie Altschul (1919–2002), a Viennese mathematics student who had specialized in psychiatric nursing at the Maudsley, became Britain’s first professor of nursing at Edinburgh. The refugees played a significant role in shaping community care policies. Former refugees trained as psychiatric social workers (especially at the London School of Economics), among these were Matilda Goldberg (1912–2004), Edith Halmos (1917–2000), and Milena Jackson. By the mid-1950s the expansion of psychiatry and child guidance services meant there were opportunities to rise to senior positions. Rather than take hard and dispiriting appointments in remote psychiatric hospitals, some former refugees opted for general practice. In the longer term, under the National Health Service, they benefited from the rise in status of the general practitioner. Their psychiatric skills stood them in good stead both in their work with patients and in supporting community care mental health options. What had begun as a range of esoteric innovations in Cinderella clinics and isolated hospitals became the basis of a national reform of British psychiatry. The refugees encountered a mixed reception in the 1930s. The hostility of the BMA was offset by support from innovative mental health centers, notably the Maudsley Hospital, Runwell, and Crichton Royal. British Freudians and other clusters of analysts gave the medical refugees considerable support. The result was to benefit hospital provision, outpatient and community services, and general practice. The refugees strengthened an already existing dynamic of reform, and their specific contributions were substantial. These favorable circumstances allowed the refugees to make a pioneering and fundamental contribution to British psychiatric reform.

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Notes 1. This figure is taken from my database of medical refugees in the United Kingdom, currently numbering approximately 5,277 individuals. 2. Mitchell G. Ash, “Central European Émigré Psychologists and Psychoanalysts in Britain,” in Second Chance: Two Centuries of German-Speaking Jews in the United Kingdom, ed. Werner E. Mosse et al. (Tübingen: Mohr, 1991), 101–20. For context, see Paul Weindling, “Medical Refugees and the Modernisation of Twentieth-Century British Medicine,” Social History of Medicine 22 (2009): 489–511. 3. Wellcome Library SA/EUG/C.157: Box AMS/MF/110. Max Hodann, History of Modern Morals, trans. Stella Browne (London: Heinemann, 1937). Ralf Dose, “No Sex Please, We’re British, oder: Max Hodann in England 1935—ein deutscher Emigrant auf der Suche nach einer Existenz,” Mitteilungen der Magnus-HirschfeldGesellschaft, 22/23 (June 1996): 99–125. 4. Charlotte Wolff, Hindsight: An Autobiography (London: Quartett, 1980). 5. Karl Stern file, MS, Society for Protection of Science and Learning Papers (SPSL), 398/9, Bodleian Library, Oxford. Karl Stern, The Pillar of Fire (Boston: Harcourt, Brace & Co., 1951). 6. Michael Gelder, “Adolf Meyer and His Influence on British Psychiatry,” in 150 Years of British Psychiatry, 1841–1991, eds. German E. Berrios and Hugh L. Freeman (London: Gaskell, 1991), 419–35. 7. A. McGehee Harvey and Susan Abrams, For the Welfare of Mankind: The Commonwealth Fund and American Medicine (Baltimore: The Johns Hopkins University Press, 1986), 29–83. 8. Yvonne Kapp and Margaret Mynatt, with a foreword by Charmian Brinson, British Policy and the Refugees, 1933–1941 (Abingdon, Oxfordshire: Frank Cass & Co. Ltd., 1997), 32. 9. See George Weisz, Divide and Conquer: A Comparative History of Medical Specialization (Oxford: Oxford University Press, 2006), 177–80. 10. Uwe Henrik Peters, Anna Freud: A Life Dedicated to Children (London: Weidenfeld, 1985); Peters, “The Psychoanalytic Exodus: Romantic Antecedents and the Loss to German Intellectual Life,” in Freud in Exile: Psychoanalysis and its Vicissitudes, ed. Edward Timms and Naomi Segal (New Haven: Yale University Press, 1988), 54–64. 11. Katherine Angel et al., eds., European Psychiatry on the Eve of War: Aubrey Lewis, the Maudsley Hospital and the Rockefeller Foundation in the 1930s (London: BPR Publishers, 2003). 12. The Jewish Health Organisation of Great Britain (London: Woburn House, 1938). 13. Carlos Paton Blacker, Neurosis and the Mental Health Services (Oxford: Oxford University Press, 1946), 3. 14. Alice von Platen Ricciardi, Biographical Recollections of the Northfield Hospital, recorded by author, tape 3, side 1. Dr. Ricciardi—at the time Alice von Platen—came to Britain after acting as German medical representative at the Nuremberg medical trial. She worked at Shenley and Bromley Hospitals and also trained in group analysis. Biologists in Search of Material, ed. G. Scott Williamson and Innes H.

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Pearse (London: Faber & Faber, 1938), 23. Innes Pearse and Lucy H. Crocker, The Peckham Experiment (London: Sir Halley Stewart Trust, 1943). 15. Henry V. Dicks, Fifty Years of the Tavistock Clinic (London: Routledge, 1970), 34–49. 16. Timms and Sigel, eds., Freud in Exile, 54–64. 17. Ash, “Émigré Psychologists,” 101–20. Michelle Moreau Ricaud, Michael Balint: Le renouveau de l’école de Budapest (Ramonville-Saint-Agne: Érès, 2000), 103, 105. Brenda Maddox, Freud’s Wizard: The Enigma of Ernest Jones (London: John Murray, 2006), 222. 18. Elke Mühlleitner and Johannes Reichmayr, “Die ‘Wiener’ Psychoanalyse im Exil,” Luzifer-Amor 16 (2003): 70–105; Mühlleitner, Biographisches Lexikon der Psychoanalyse: die Mitglieder der Psychologischen Mittwoch-Gesellschaft und der Wiener Psychoanalytischen Vereinigung von 1902–1938 (Tübingen: Diskord, 1992). 19. Gregorio Kohon, “Notes on the History of the Psychoanalytic Movement in Great Britain,” in The British School of Psychoanalysis: The Independent Tradition, ed. Gregorio Kohon (London: Free Association Books, 2008). 20. Kapp and Mynatt, British Policy and the Refugees, 29–30. 21. Aubrey Lewis, “William Mayer-Gross: An Appreciation,” Psychological Medicine 7 (1977): 11–18. 22. W. Rees Thomas and Isabel G. H. Wilson, Report on Cardiazol Treatment and on the Present State of Hypoglycaemic Shock Treatment in Schizophrenia (London: HMSO, 1938). 23. Pamela Michael, Care and Treatment of the Mentally Ill in North Wales, 1800– 2000 (Cardiff: University of Wales Press, 2003), 132–34, 141, 166, 168. Ernst Schwarz, “Depression in Parkinsonism Treated by Prefrontal Leucotomy,” Journal of Mental Science 91 (1945): 503 24. Rockefeller Archive Center, Sleepy Hollow, New York (hereafter RAC), folder 42, box 4, series 1.1, Record Group (hereafter RG) 6.1. 25. Paul Weindling, “An Overloaded Ark? The Rockefeller Foundation and Refugee Medical Scientists, 1933–1945,” Studies in the History and Philosophy of Biology and Biomedical Science 31 (2000): 477–89. 26. RAC, folder 41, box 4, series 1.1, RG 6.1. Grant for Guttmann, 24 February 1934 (and 6 June 1940). Golla on Meyer 20 November 1934. 27. RAC, folder 42, box 4, series 1.1, RG 6.1. Grant for Plaut, 6 September 1939. 28. BMA Archives, B/12/1/1, London, BMA Aliens Committee, 1939–49. 29. Uwe Henrik Peters, “The Emigration of German Psychiatrists to Britain,” in 150 Years of British Psychiatry, Volume II: The Aftermath, eds. German Berrios and Hugh Freeman (London: Athlone, 1996), 567. 30. Martin Stanton, “Wilhelm Stekel: A Refugee Analyst and His English Reception,” in Freud in Exile, 163–74. 31. Moreau Ricaud, Balint. 32. See Eric Guttmann and W. Mayer-Gross, “Psychology of Mutilation and Disablement,” The Lancet (17 August 1940): 185–86. 33. Erwin Stengel file, MS, SPSL, 398/7, 28 January 1939. 34. BMA Archives, B/12/1/1, Home Office Medical Advisory Committee, 21 August 1940, p. 5.

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35. Ibid., 24 November 1941, p. 8. 36. Ibid., 8 January 1943. Moreau Ricaud, Balint. 37. Moreau Ricaud, Balint, 124. 38. BMA Archives, Home Office Medical Advisory Committee, 17 February 1943. 39. Ibid., 15 October 1943. 40. “Joshua Bierer,” British Medical Journal 290 (12 January 1985): 163–64. Liam Clarke, “Joshua Bierer: Striving for Power,” History of Psychiatry 8 (1997): 319–32. 41. Edward Timms, “New Approaches to Child Psychology: From Red Vienna to the Hampstead Nursery,” in Intellectual Migration and Cultural Transformation: Refugees from National Socialism in the English-speaking World, ed. Edward Timms and Jon Hughes (New York: Springer, 2003), 219–40. 42. Anna Freud with Dorothy Burlingham, Infants without Families: Reports on the Hampstead Nurseries 1939–1945, The Writings of Anna Freud, vol. 3 (New York: International Universities Press, 1973); Anna Freud, The Psycho-Analytical Treatment of Children (London: Imago, 1946); Dorothy Burlingham, Twins: A Study of Three Pairs of Identical Twins (London: Imago, 1952); Uwe Henrik Peters, Anna Freud; Elisabeth YoungBruehl, Anna Freud (London: Macmillan, 1988), 246–57; Erich Wittkower, “Studies in the Influence of the Emotions on the Functions of the Organs,” Journal of Mental Science 81 (1935): 533–682. 43. Kate Friedlaender’s name appears in the anglicized form of Friedlander. She was also mentioned in the Kapp refugee list as Misch-Friedlaender. For biographical details see Werner Röder and Herbert A. Strauss, eds., Handbuch der deutschsprachigen Emigration nach 1933, International Biographical Dictionary of Central European Émigrés 1933–1945, 2 vols. (Munich: Saur Verlag, 1983). 44. RAC RF 12.1; Gregg Diary, Box 22, 14 May 1942. 45. Young-Bruehl, Anna Freud, 249. 46. Humberto Nagara, ed., The Hampstead Clinic Psychoanalytic Library (London: Maresfield Reprints, 1981); Young-Bruehl, Anna Freud, 250; Janet Sayers, Mothering Psychoanalysis: Helene Deutsch, Karen Horney, Anna Freud and Melanie Klein (Harmondsworth: Penguin, 1992). 47. Young-Bruehl, Anna Freud, 331–33. 48. Phylis Grosskurth, Melanie Klein (London: Hodder, 1985), 281–309. Brenda Maddox, Freud’s Wizard: The Enigma of Ernest Jones (London: John Murray, 2006). 49. Robert M. Young, “Melanie Klein I,” http://www.human-nature.com/rmyoung/papers/pap127h.html (accessed 28 June 2009). 50. Phyllis Bottome, Alfred Adler: Apostle of Freedom (London: Faber & Faber, 1939), 300–1; Sicher, “Memorial Address,” 343–53. 51. BMA Archives, Home Office Medical Advisory Committee, 101 and 111, 1944. 52. Alice von Platen Ricciardi, Biographical Recollections of the Northfield Hospital, recorded by author, tape 3, side 1. 53. F. Alec Jenner, “Erwin Stengel: A Personal Memoir,” in 150 Years of British Psychiatry 1841–1991, 436–44; Erwin Stengel, “On Learning a New Language,” International Journal of Psychoanalysis 20 (1939): 1–8. 54. Minute Book, Warneford and Park Hospitals Management Committee, 23 February 1955, W.AddV/241/a Oxfordshire Health Archives, Oxford.

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55. Charles Webster, The Health Services since the War, vol. 1 (London: HMSO, 1988), 255, 340. 56. Hans Eysenck, Dimensions of Personality (London: Routledge, 1947); Hilde T. Himmelweit, A Study of Temperament of Neurotic Persons by Means of Level of Aspiration Tests (PhD diss., University of London, Institute of Psychiatry, 1945); Hamilton B. Gibson, Hans Eysenck: The Man and his Work (London: Peter Owen, 1981). 57. “Stephanie Felsenburg Obituary,” British Medical Journal (30 April 1977): 1165. 58. Sabine Strich file, Oxford Brookes University, The Centre for Health, Medicine and Society (hereafter CfHMS), European medical refugees collection. 59. Felix Post file, Zentrum für Antisemitismus, Technische Universität Berlin, and Oxford Brookes University, CfHMS, European medical refugees collection. Felix Post, “The Outcome of Mental Breakdown in Old Age,” British Medical Journal (1951): 436–48. Felix Post, The Significance of the Affective Symptoms in Old Age, Maudsley Monographs 10 (London: Oxford University Press, 1962); Moira Martin, “Medical Knowledge and Medical Practice: Geriatric Medicine in the 1950s,” Social History of Medicine 8 (1995): 443–61. 60. Tom Arie file, Oxford Brookes University, CfHMS, European medical refugees collection. 61. RAC, folder 42, box 4, series 1.1, RG 6.1. 62. Richard Hunter and Ida Macalpine, Psychiatry for the Poor: 1851 Colney Hatch Asylum-Friern Hospital 1973: A Medical and Social History (London: Dawsons of Pall Mall, 1974); Roy Porter, “Ida Macalpine and Richard Hunter: History between Psychoanalysis and Psychiatry,” in Discovering the History of Psychiatry, ed. Mark Micale and Roy Porter (Oxford: Oxford University Press, 1994), 83–94; Roy Porter, “Psychiatry and Its History: Hunter and Macalpine,” in Proceedings of the 1st European Congress on the History of Psychiatry and Mental Health Care, ‘s-Hertogenbosch, The Netherlands, 24–26 October 1990 (Rotterdam: Erasmus Publishing, 1993), 167–77. 63. Karl Richard König, Autobiographisches Fragment, ed. Camphill Friends’ Circle, 1979 (an incomplete publication of the first part of a Geschichte Camphills [History of Camphill] that König began in the 1960s but did not finish [Camphill, Aberdeen: Karl König Archive, 1979]); Hans Müller-Wiedemann, Karl König, A Central-European Biography of the Twentieth Century, trans. Simon Blaxland-de Lange (Botton Village: Camphill Books, 1996).

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Selected Bibliography This bibliography provides a selection of secondary sources (monographs and journal articles) on the general topic of this volume. Full citations for primary sources are given in the endnotes of individual chapters. Allderidge, Patricia. “The Foundation of the Maudsley Hospital.” In 150 Years of British Psychiatry, 1841–1991, edited by German Berrios and Hugh Freeman, 79– 88. London: Gaskell, 1991. Angel, Katherine. “Defining Psychiatry: Aubrey Lewis’s 1938 Report and the Rockefeller Foundation.” In European Psychiatry on the Eve of War: Aubrey Lewis, The Maudsley Hospital, and the Rockefeller Foundation in the 1930s, edited by Katherine Angel, Edgar Jones, and Michael Neve, 39–56. Medical History, Supplement 22. London: The Wellcome Trust Centre for the History of Medicine at UCL, 2003. Ash, Mitchell. “Internationalisierung und Entinternationalisierung der Wissenschaften im 19. und 20. Jahrhundert: Thesen.” In Zeitgeschichte.at. Österreichischer Zeithistorikertag 1999, edited by Manfred Lechner and Dietmar Seiler, 4–12. Innsbruck: Studien-Verlag, 2000. Ash, Mitchell, and Alfons Söllner, eds. Forced Migration and Scientific Change: Émigré German-Speaking Scientists after 1933. Cambridge: Cambridge University Press, 1996. Bayly, Christopher A., Sven Beckert et al., “AHR Conversation: On Transnational History.” American Historical Review 111 (2006): 1441–64. Berrios, German, and Hugh Freeman, eds. 150 Years of British Psychiatry, 1841–1991. London: Gaskell, 1991. Bonner, Thomas Neville. American Doctors and German Universities: A Chapter in International Intellectual Relations, 1870–1914. Lincoln: University of Nebraska Press, 1963. Brown, Theodore. “Alan Gregg and the Rockefeller Foundation’s Support of Franz Alexander’s Psychosomatic Research.” Bulletin of the History of Medicine 61 (1987): 155–86. Burnham, John C. Jelliffe: American Psychoanalyst and Physician, and His Correspondence with Sigmund Freud and C. G. Jung, edited by William McGuire. Chicago: University of Chicago Press, 1983. ———. “The Transit of Medical Ideas: Changes in Citation of European Publications in USA Biomedical Journals.” In Actas del XXXIII Congreso International de Historia de la Medicina, edited by V. Juan Luis Carillo and Guillermo Olagüe de Ros, 101–12. Sevilla: Sociedad Española de Historia de la Medicina, 1994. Crawford, Elisabeth. Nationalism and Internationalism in Science, 1880–1939. Cambridge: Cambridge University Press, 1992.

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Dikötter, Frank. “Race Culture: Recent Perspectives on the History of Eugenics.” American Historical Revue 103 (1998): 467–78. Dowbiggin, Ian R. Keeping America Sane: Psychiatry and Eugenics in the United States and Canada, 1880–1940. Ithaca: Cornell University Press, 1997. Engstrom, Eric J. Clinical Psychiatry in Imperial Germany: A History of Psychiatric Practice. Ithaca: Cornell University Press, 2003. ———. “Emil Kraepelin: Psychiatry and Public Affairs in Wilhelmine Germany.” History of Psychiatry 2 (1991): 111–32. Eric J. Engstrom, and Volker Roelcke, eds. Psychiatrie im 19. Jahrhundert: Forschungen zur Geschichte von psychiatrischen Institutionen, Debatten und Praktiken im deutschen Sprachraum. Basel: Schwabe, 2003. Freeman, Hugh, and German Berrios, eds. 150 Years of British Psychiatry, Volume II: The Aftermath. London: Athlone, 1996. Gelder, Michael. “Adolf Meyer and His Influence on British Psychiatry.” In 150 Years of British Psychiatry, 1841–1991, edited by German Berrios and Hugh Freeman, 419–35. London: Gaskell, 1991. Geyer, Martin H., and Johannes Paulmann, eds. The Mechanics of Internationalism: Culture, Society, and Politics from the 1840s to the First World War. Oxford: Oxford University Press, 2001. Gijswijt-Hofstra, Marijke, and Roy Porter, eds. Cultures of Psychiatry and Mental Health Care in Postwar Britain and the Netherlands. Amsterdam: Rodopi, 1998. Gijswijt-Hofstra, Marijke, Harry Oosterhuis, Joost Vijselaar, and Hugh Freeman, eds. Psychiatric Cultures Compared: Psychiatry and Mental Health Care in the Twentieth Century. Amsterdam: Amsterdam University Press 2005. Goldberg, Ann. “A Reinvented Public: ‘Lunatics Rights’ and Bourgeois Populism in the Kaiserreich.” In Psychiatrie im 19. Jahrhundert: Forschungen zur Geschichte von psychiatrischen Institutionen, Debatten und Praktiken im deutschen Sprachraum, edited by Eric J. Engstrom and Volker Roelcke, 189–217. Basel: Schwabe, 2003. Goldstein, Jan. Console and Classify: The French Psychiatric Profession in the Nineteenth Century. Cambridge: Cambridge University Press 1987. Grob, Gerald N. Mental Illness and American Society, 1875–1940. Princeton: Princeton University Press, 1983. Jackson, Mark. The Borderland of Imbecility: Medicine, Society, and the Fabrication of the Feeble Mind in Late Victorian and Edwardian England. Manchester: Manchester University Press, 2000. Kortländer, Bernd. “Begrenzung—Entgrenzung: Kultur- und Wissenschaftstransfer in Europa.” In Nationale Grenzen und internationaler Austausch: Studien zum Kultur- und Wissenschaftstransfer in Europa, edited by Lothar Jordan and Bernd Kortländer, 1–19. Tübingen: Niemeyer, 1995. Lawrence, Christopher. “Still Incommunicable: Clinical Holists and Medical Knowledge in Interwar Britain.” In Greater than the Parts: Holism in Biomedicine, 1920–50, edited by Christopher Lawrence and George Weisz, 94–111. Oxford: Oxford University Press, 1998. Michael, Pamela. Care and Treatment of the Mentally Ill in North Wales 1800–2000. Cardiff: University of Wales Press, 2003.

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Noll, Richard. “Styles of Psychiatric Practice, 1906–1925: Clinical Evaluations of the Same Patient by James Jackson Putnam, Adolph Meyer, August Hoch, Emil Kraepelin, and Smith Ely Jelliffe.” History of Psychiatry 10 (1999): 145–89. Paulmann, Johannes. “Internationaler Vergleich und interkultureller Transfer. Zwei Forschungsansätze zur europäischen Geschichte des 18. bis 20. Jahrhunderts.” Historische Zeitschrift 267 (1998): 649–85. Peters, Uwe-Henrik. Psychiatrie im Exil: Die Emigration der dynamischen Psychiatrie aus Deutschland 1933–1939. Düsseldorf: Kupka, 1992. Porter, Roy, and David Wright, eds. The Confinement of the Insane, International Perspectives, 1800–1965. Cambridge: Cambridge University Press, 2003. Ritter, Hans-Jakob, and Volker Roelcke. “Psychiatric Genetics in Munich and Basel between 1925 and 1945: Programs—Practices—Cooperative Arrangements.” Osiris 20 (2005): 263–88. Röder, Werner, and Herbert A. Strauss, eds. Handbuch der deutschsprachigen Emigration nach 1933/International Biographical Dictionary of Central European Émigrés 1933– 1945. 2 vols. Munich: Saur, 1983. Roelcke, Volker. “Psychiatrische Wissenschaft im Kontext nationalsozialistischer Politik und ‘Euthanasie’: Zur Rolle von Ernst Rüdin und der Deutschen Forschungsanstalt/ Kaiser-Wilhelm-Institut für Psychiatrie.” In Die Kaiser-Wilhelm-Gesellschaft im Nationalsozialismus: Bestandsaufnahme und Perspektiven der Forschung, edited by Doris Kaufmann, 112–50. Göttingen: Wallstein, 2000. ———. “Die Entwicklung der Psychiatrie 1880–1932: Theoriebildung, Institutionen, Interaktionen mit zeitgenössischer Wissenschafts- und Sozialpolitik.” In Wissenschaften und Wissenschaftspolitik: Bestandsaufnahmen zu Formationen, Brüchen und Kontinuitäten im Deutschland des 20. Jahrhunderts, edited by Rüdiger vom Bruch and Brigitte Kaderas, 109–24. Stuttgart: Franz Steiner 2002. ———. “Unterwegs zur Psychiatrie als Wissenschaft: Das Projekt einer ‘Irrenstatistik’ und Emil Kraepelins Neuformulierung der psychiatrischen Klassifikation.” In Psychiatrie im 19. Jahrhundert: Forschungen zur Geschichte von psychiatrischen Institutionen, Debatten und Praktiken im deutschen Sprachraum, edited by Eric J. Engstrom and Volker Roelcke, 169–88. Basel: Schwabe, 2003. ———. “Continuities or Ruptures? Concepts, Institutions, and Contexts of Twentieth-Century German Psychiatry and Mental Health Care.” In Psychiatric Cultures Compared: Psychiatry and Mental Health Care in the Twentieth Century, edited by Marijke Gijswijt-Hofstra, Harry Oosterhuis, Joost Vijselaar, and Hugh Freeman, 162–82. Amsterdam: Amsterdam University Press, 2005. ———. “Funding the Scientific Foundations of Race Policies: Ernst Rüdin and the Impact of Career Resources on Psychiatric Genetics, ca 1910–1945.” In Man, Medicine, and the State: The Human Body as an Object of Government Sponsored Medical Research in the 20th Century, edited by Wolfgang U. Eckart, 72–87. Stuttgart: Franz Steiner, 2006. ———. “Die Etablierung der psychiatrischen Genetik in Deutschland, Großbritannien und den USA, ca. 1910–1960. Zur untrennbaren Geschichte von Eugenik und Humangenetik.” Acta Historica Leopoldina 48 (2007): 173–90. Rose, Nicholas. The Psychological Complex: Social Regulation and the Psychology of the Individual. London: Routledge, 1985.

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Schmiedebach, Heinz-Peter. “Eine ‘anti-psychiatrische’ Bewegung um die Jahrhundertwende.” In Medizinkritische Bewegungen im Deutschen Reich (ca. 1870–1933), edited by Martin Dinges, 127–59. Stuttgart: Steiner, 1996. Schmiedebach, Heinz-Peter, and Stefan Priebe. “Open Psychiatric Care and Social Psychiatry in 19th and Early 20th Century Germany.” In Psychiatrie im 19. Jahrhundert: Forschungen zur Geschichte von psychiatrischen Institutionen, Debatten und Praktiken im deutschen Sprachraum, edited by Eric J. Engstrom and Volker Roelcke, 263–81. Basel: Schwabe, 2003. Schneider, William H. Rockefeller Philanthropy and Modern Biomedicine: International Initiatives from World War I to the Cold War. Bloomington: Indiana University Press, 2002. ———. “The Model American Foundation Officer: Alan Gregg and the Rockefeller Foundation.” Minerva 41 (2003): 155–66. Scull, Andrew. Museums of Madness: The Social Organization of Insanity in NineteenthCentury England. London: Allen Lane, 1979. Shepherd, Michael. A Representative Psychiatrist: The Career, Contributions, and Legacies of Sir Aubrey Lewis. Cambridge: Cambridge University Press, 1987. Thomson, Mathew. “Mental Hygiene as an International Movement.” In International Health Organizations and Movements, 1918–1939, edited by Paul Weindling, 283– 304. Cambridge: Cambridge University Press, 1995. ———. The Problem of Mental Deficiency: Eugenics, Democracy, and Social Policy in Britain, c. 1870–1959. Oxford: Clarendon Press, 1998. Trent, James W. Inventing the Feeble Mind: A History of Mental Retardation in the United States. Berkeley and Los Angeles: University of California Press, 1994. Warner, John Harley. Against the Spirit of System: The French Impulse in Nineteenth-Century American Medicine. Princeton: Princeton University Press, 1998. Weber, Matthias M. “Psychiatric Research and Science Policy in Germany: The History of the Deutsche Forschunganstalt für Psychiatrie (German Institute for Psychiatric Research) in Munich from 1917 to 1945.” History of Psychiatry 11 (2000): 235–58. Weindling, Paul J. “The Rockefeller Foundation and German Biomedical Science, 1920–1940: From Educational Philanthropy to International Science Policy.” In Science, Politics, and the Public Good, edited by Nicholaas Rupke, 119–40. Basingstoke: Macmillan, 1988. ———. Health, Race, and German Politics between National Unification and Nazism. Cambridge: Cambridge University Press, 1989. ———. “The Contribution of Central European Jews to Medical Science and Practice in Britain, the 1930s to the 1950s.” In Second Chance: Two Centuries of German Speaking Jews in the United Kingdom, edited by Werner Mosse and Julius Carlebach, 243–54. Tübingen: J. C. Mohr, 1991. ———. “International Eugenics: Swedish Sterilization in Context.” Scandinavian Journal of History 24 (1999): 179–97. ———. “An Overloaded Ark? The Rockefeller Foundation and Refugee Medical Scientists, 1933–1945.” Studies in History and Philosophy of Biological and Biomedical Sciences 31C (2000): 477–89.

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———. “Medical Refugees in Wales.” In Health and Society in Twentieth-Century Wales, edited by Pamela Michael and Charles Webster, 183–200. Cardiff: University of Wales Press, 2006. ———. John W. Thompson: Psychiatrist in the Shadow of the Holocaust. Rochester, NY: University of Rochester Press, 2010 (in press). Werner, Michael. “Maßstab und Untersuchungsebene: Zu einem Grundproblem der vergleichenden Kulturtransfer-Forschung.” In Nationale Grenzen und internationaler Austausch: Studien zum Kultur- und Wissenschaftstransfer in Europa, edited by Lothar Jordan and Bernd Kortländer, 20–33. Tübingen: Niemeyer, 1995. Werner, Michael, and Bénédicte Zimmermann. “Beyond Comparison. Histoire Croisée and the Challenge of Reflexivity.” History and Theory 45 (2006): 30–50. Westwood, Louise. “Separatism and Exclusion: Women in Psychiatry, 1900–50.” In Mental Illness and Learning Disability since 1850: Finding a Place for Mental Disorder in the United Kingdom, edited by Pamela Dale and Joseph Melling (London: Routledge, 2006)

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Contributors John C. Burnham is research professor of history, professor of psychiatry (by courtesy), and associated scholar in the Medical Heritage Center at The Ohio State University. He is the author of How the Idea of Profession Changed the Writing of Medical History, Medical History Supplement 18 (London: Wellcome Institute for the History of Medicine, 1998); What Is Medical History? (Cambridge: Polity, 2005), and, most recently, Accident Prone: A History of Technology, Psychology, and Misfits of the Machine Age (Chicago: University of Chicago Press, 2009). Eric J. Engstrom is research associate at the Department of History, Humboldt University, Berlin. He has published widely on the cultural history of psychiatry and is the author of Clinical Psychiatry in Imperial Germany: A History of Psychiatric Practice (Ithaca: Cornell University Press, 2003), and coeditor (with Volker Roelcke) of Psychiatrie im 19. Jahrhundert: Forschungen zur Geschichte von psychiatrischen Institutionen, Debatten und Praktiken im deutschen Sprachraum (Basel: Schwabe, 2003). Rhodri Hayward is Wellcome Award Lecturer at Queen Mary’s College, University of London. He is the author of Resisting History: Popular Religion and the Origins of the Unconscious (Manchester: Manchester University Press, 2007), and Self Cures: Psychology and Medicine in Modern Britain (forthcoming). Mark Jackson is professor of the history of medicine and director of the Centre for Medical History at the University of Exeter. He is the author of The Borderland of Imbecility: Medicine, Society, and the Fabrication of the Feeble Mind in Late Victorian and Edwardian England (Manchester: Manchester University Press, 2000), Allergy: The History of a Modern Malady (London: Reaktion Books, 2006), Asthma: The Biography (Oxford: Oxford University Press, 2009), as well as numerous edited volumes and articles. He is currently writing a monograph on the history of stress. Pamela Michael is lecturer in health and social care at the School of Social Sciences at Bangor University, Bangor (Wales, UK). She is the author of Care and Treatment of the Mentally Ill in North Wales, 1800–2000 (Chicago: University of Chicago Press, 2003) and coeditor (with Charles Webster) of Health and Society in Twentieth-Century Wales (Chicago: University of Chicago Press, 2006).

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Hans Pols is senior lecturer in the Department of History and Philosophy of Science, University of Sydney, Australia. He has published widely on the social and cultural history of psychology and mental health care, and on the history of psychiatry in the Dutch East Indies. Volker Roelcke is professor of the history of medicine at Giessen University, Germany. He is the author of Krankheit und Kulturkritik: Psychiatrische Gesellschaftsdeutungen im bürgerlichen Zeitalter, 1790–1914 (Frankfurt: Campus, 1999). He is also coeditor (with Eric Engstrom) of Psychiatrie im 19. Jahrhundert: Forschungen zur Geschichte von psychiatrischen Institutionen, Debatten und Praktiken im deutschen Sprachraum (Basel: Schwabe, 2003), and (with Jürgen Reulecke) of Wissenschaften im 20. Jahrhundert: Universitäten in der modernen Wissenschaftsgesellschaft (Stuttgart: Steiner, 2008). Heinz-Peter Schmiedebach is professor and director, Institute for the History and Ethics of Medicine, Hamburg University. He is the author of Psychiatrie und Psychologie im Widerstreit: Die Auseinandersetzung in der Berliner medicinisch-psychologischen Gesellschaft, 1867–1899 (Husum: Matthiesen, 1986), Robert Remak (1815– 1865): Ein jüdischer Arzt im Spannungsfeld von Wissenschaft und Politik (Stuttgart: Gustav Fischer, 1995), as well as numerous edited volumes and articles. Mathew Thomson is reader in the Department of History, University of Warwick, UK. He is the author of The Problem of Mental Deficiency: Eugenics, Demography, and Social Policy in Britain, 1870–1959 (Oxford: Oxford University Press, 1998), and of Psychological Subjects: Identity, Culture, and Health in Twentieth-Century Britain (Oxford: Oxford University Press, 2006). Paul J. Weindling is professor of the history of medicine in the Department of History, Oxford Brookes University. His publications include Health, Race, and German Politics between National Unification and Nazism (Cambridge: Cambridge University Press, 1989), Epidemics and Genocide in Eastern Europe, 1890–1945 (Oxford: Oxford University Press, 2000), and Nazi Medicine and the Nuremberg Trials: From Medical War Crimes to Informed Consent, 1945–55 (New York: Palgrave Macmillan, 2004; paperback 2006). He recently completed John W. Thompson: Psychiatrist in the Shadow of the Holocaust (Rochester, NY: University of Rochester Press, 2010). Louise Westwood is a retired lecturer and honorary research reader in the Department of History at the University of Sussex. Her most recent publications are “Separatism and Exclusion: Women in Psychiatry, 1900–1950,” Mental Illness and Learning Disability since 1850: Finding a Place for Mental Disorder in the United Kingdom, ed. Pamela Dale and Joseph Melling (London: Routledge, 2006), and “Care in the Community of the Mentally Disordered: The Case of the Guardianship Society, 1900–1939,” Social History of Medicine 20 (2007).

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Index Academic Assistance Council, 78, 79 Adler, Alfred, 102, 165, 169, 221, 226, 228, 230 Adler, Gerhard, 228 Agricultural Research Council, 213 Albert Einstein Medical College, New York, 163 Allgemeine Zeitschrift für Psychiatrie, 15, 101–3 Altschul, Annie, 231 Alzheimer, Alois, 52, 65n48, 70 American Journal of Insanity, 97–98. See also American Journal of Psychiatry American Journal of Psychiatry, 97–99, 157 American Medico-Psychological Association, 159 American Psychiatric Association, 112 American Psychoanalytic Association, 114 American Relief Administration, 100 Angell, James Rowland, 157, 159, 160, 162, 167, 171 anti-psychiatry movement, 14, 23 Antonovitch, Stella, 73, 80 Antwerp Mental Hospital, 69 Archives of Neurology, 67 Arie, Tom, 230, 235n60 Armutspychiatrie, 22 Ash, Mitchell, 80 Ashley, Lord, 15 asylum(s); and nonrestraint, 13, 17–19, 24; architecture of, 3, 16; British vs. German model, 12–25; overcrowding of, 15, 20; public and private, 21–22; supervision of, 50; urban and rural, 18–19 Baker, 189 Baker, Lewellys, 160

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Baldwin, 186 Balint, Alice, 224 Balint, Michael, 220, 223, 226 Barnhill Parochial Hospital, Glasgow, 179 Bartlett, Frederic, 79 Bavarian Medical Board, 53 Baylor Medical School, Houston, Texas, 170, 173 Beach, Fletcher, 37, 40 Beck, Adolf, 79 Beck, Elizabeth, 89n75 Beers, Clifford W., 126n1, 134, 135, 158, 162, 190 Benedict, Ruth, 124 Berkenau, Paul, 224, 229 Berlin Dalldorf Asylum, 22 Berndt-Guttfeld, Lisbeth, 230 Beveridge, William, 78, 223 Beveridge Report, 222 Bierer, Joshua, 219, 226, 228 Bion, Wilfried, 228 Blake, Louisa Aldrich, 185 Blaker, Carlos Paton, 76 Blasius, Dirk, 22 Board of Control, 7, 139, 143–44, 180, 183–84, 188, 190, 200, 205–8, 223 Board of Education, 34, 38, 41 Board of Lunacy, 179, 180 Board of Lunacy Commissioners, 17 Boas, Franz, 162 Bolton, James Shaw, 72 Bonhoeffer, Karl, 77, 199 Boston Psychopathic Hospital, 203 Bostroem, August, 102, 109n46, 166 Bowlby, John, 227 Boyle, Helen, 6, 145, 179–85, 190–91 Brady, Cheyne, 40 Brazier, Molly, 79

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Bristol Mental Hospital, 225 British Hospital for Nervous Disorder, 180, 186 British Medical Association (BMA), 71, 220, 223–26, 229, 231; Aliens Committee of, 224 British Medical Journal, 39, 68, 69 British National Council for Mental Hygiene, 113, 135 British Psychoanalytic Society, 222 Brock, Laurence, 139 Brock Committee, 74 Brodmann, Korbinius, 99 Bronner, Augusta, 119 Bumke, Oswald, 99, 102, 163, 166, 168 Bumm, Anton, 52 Burnham, John, 4, 112 Burtt, Cyrill, 230 Butler Hospital, Providence, Rhode Island, 161 Buzzard, Farquhar, 71 Camphill, 231 Canning Town Medical Mission, London, 181 Cantor, David, 76 Cardiff City Mental Hospital, 197–99, 208–11 Cardiff Mental After-Care Committee, 204 Carnegie Foundation, 55, 157, 160 Caro, Amalie, 57 Caro, Heinrich, 57 Carswell, John, 179, 180, 181, 190 Cassel, Ernest, 145 Cassel Hospital, 71, 145 Central Association for Care of Mental Defectives, 135 Central Association for Mental Welfare, 135, 140 Central Office of Refugees’ Medical Department, 223 Charcot, Jean-Martin, 69, 184 Charing Cross Hospital, 180 Charité Hospital, 17, 22, 78, 79 Charity Organisation Society, 36, 38 Child Guidance Council, 136, 205

Roelcke.indd Sec1:246

Chorlton and Manchester Joint Asylum Committee, 39 Clapton Asylum, 31, 34 Claybury Asylum, 69, 181, 200 clinic(s): child guidance, 112, 119–20, 136, 147, 171, 205, 221, 228, 230 (see also East London Child Guidance Clinic); outpatient, 112–15, 180, 120, 137, 143, 147, 158, 180–81, 200–201, 203–5, 222; psychiatric, 48, 52, 67–69, 119–20, 143, 156–57, 162–63, 180–83, 187, 189, 199, 200–202, 204, 207, 223, 227, 229–31 Cobb, Stanley, 162 Collins, William, 69 Colney Hatch Asylum, 19, 230 committee on the status of British psychiatry, 69 Commonwealth Fund, 5, 78, 119, 120, 147, 162, 205, 220, 223, 227 community care, 142, 190, 230, 231 community mental health movement, 123, 125 Cotton, Henry, 102 Craig, Maurice, 69, 113, 145, 190 Craig, Roy N., 228 Cramer, August, 182 Creak, Mildred, 79 Crichton Royal Asylum, 228, 231 Crichton-Browne, James, 199, 203 Curran, Desmond, 78 Cushing, Harvey, 99, 162 Cygnaeus, Uno, 42 Daily Telegraph, 188 Dale, Henry Hallett, 210 Damerow, Heinrich Philipp August, 15 Dandy, Walter, 99 Dann, Gertrud, 227 Dann, Sophie, 227 Darenth Asylum, 31, 37 degeneration, 7, 32, 51, 57, 70, 164 Déjérine, Joseph J., 94, 204, 215n38 Dendy, Mary, 30, 32, 34–35, 38–41 Departmental Committee on Defective and Epileptic Children, 33 Dewey, John, 113, 120, 160

4/17/2010 10:20:34 AM

index Dick, Hermann, 17–18 Dickens, Jane B., 38 Domarus, Eilhard von, 156 Dubois, Paul, 94, 112, 121 Duisberg, Carl, 56 Duke University School of Medicine, 213 Duncan, P. Martin, 38 East London Child Guidance Clinic, 147, 221, 227 Eastern Counties Asylum, 38 Ebbinghaus, Hermann, 160 Eddington, Arthur, 74 Edinburgh University, 185 Edsell, David, 160 Eicholz, Alfred, 33, 39 Elementary Education (Defective and Epileptic Children) Act, 32, 33 Engl, Hanna (later Kennedy), 227 Engstrom, Eric, 6, 67, 182, 183 Esquirol, Jean-Etienne Dominique, 37 eugenics, 5, 8, 70; and American mental hygiene, 114, 116–17; and British mental hygiene, 7, 137–41, 149–50; psychiatric, 74 Eugenics Record Office, 116 Eugenics Review, 75 Eugenics Society, 76, 139 euthanasia, 78 Evans, A. E., 206 Evans, Tom, 205 Evening Standard, 188 Eysenck, Hans, 229, 230 family care, 12, 19–22. 24 Felsenburg, Stefanie, 230 Ferenczi, Sandor, 102 Fernald, Walter, 40 Fisher, Klaus, 80 Flemming, Carl Friedrich, 15 Fletcher, Walter, 210, 213 Flexner, Abraham, 108n34, 161, 202 Ford, Henry, 59 Ford Motor Company, 59 Ford Republic for delinquent boys, 41 Forel, August, 113

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247

Foulkes, Michael (Fuchs, Siegfried), 228 Fourth London Hospital, 73 Frankenstein, Grete, 103 Frankfurt Clinic, 206 Freud, Anna, 220, 227–28 Freud, Ernst, 229 Freud, Sigmund, 72, 74, 95, 96, 112, 114, 121, 134, 146, 165, 169, 172, 184, 202–3, 219, 220, 222, 225, 229, 230 Freudenberg, Rudolf, 230 Friedlander (Friedlaender), Kate, 227 Friern Hospital, 230–33 Froebel, Friedrich, 37–38, 41–42 Froebel Society of London, 38 Fromm, Erich, 124 Gaupp, Robert, 52, 93, 101 genetics, 2, 76, 80, 165; psychiatric, 5, 73, 141, 168, 221 George, Lloyd, 186 German Psychiatric Research Institute (Deutsche Forschungsanstalt für Psychiatrie), 5, 6, 55–61, 64n44, 72, 74, 79, 157, 163, 169, 186, 219 German Society for Mental Hygiene (Deutscher Verband für Psychische Hygiene), 113 Gesell, Arnold, 171 Gesellschaft Deutscher Naturforscher und Ärzte, 19 Gesellschaft Deutscher Nervenärzte, 100 Glover, Edward, 149 Goddard, Henry H., 116 Goldberg, Ann, 23 Goldberg, Matilda, 231 Goldberger, Alice, 227 Golla, Frederick Lucien, 6, 70–71, 73–74, 76–80, 84n27, 209, 216n63, 221, 224 Goodall, Edwin, 198–202, 205, 210, 211, 215n23 Graham, James, 15 Gregg, Alan, 5, 77, 146, 213, 224 Griesinger, Wilhelm, 18 Grob, Gerald, 113 Grotjahn, Martin, 100–102

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Grünthal (Gruenthal), Ernst, 173 Gütersloh Hospital, 206 Guggenheim, Max, 211 Guttmann, Eric (Erich), 79–80, 89n75, 224

Hutton, Tom, 185 Huxley, Aldous, 219 Huxley, Julian, 210 Huxley, Thomas, 114

Haenel, Hans, 100 Haldane Commission, 202 Hall, Clark, 172 Halmos, Edith, 231 Hamburger, Käthe, 228 Hampstead Asylum, 31 Hampstead War Nurseries, 227 Harmsworth, Cecil, 82n7 Harnack, Adolf von, 54 Harpurhey Hall Special School, Manchester, 38 Hart, Bernard, 72, 74 Harvard Medical School, 162 Hayes, Sarah, 42 Hayward, Rhodri, 4 Haywards Heath Asylum, 19 Head, Henry, 186 Healy, William, 119 Heinsheimer, Alfred, 58 Hellman, Ilse, 227 Henderson, David, 7, 219 Henry Phipps Clinic, 189 Hill, Archibald Vivian, 78 Himmelweit, Hilde, 230 histoire croisée, 3 historiography of psychiatry, 1, 48, 175n25, 197 Hodann, Max, 219 Home and School Council, 136, 148 Home Office, and medical refugees, 224–26 Hopkins, Gowland, 210 Horney, Karen, 124 Horton Mental Hospital, 142, 206, 224 Howe, Samuel Gridley, 40 Hughes, Sydney, 200 Hughes, Thomas, 201 Human Welfare Group, 160, 162 Humboldt, Wilhelm von, 14 Hunter, Richard, 231 Hutton, Isabel Emslie, 6, 179, 185–90, 202

Illenau Asylum, Baden, 16, 206 Imperial College, London, 199, 210 Indian Red Cross Welfare Service, 190 industrialization, 1, 16 Institute of Human Relations, 157, 160– 61, 167, 170–72 Institute of Psychiatry, London, 4 Insurance Act, 198 Interdepartmental Committee on Physical Deterioration, 33 International Committee for Mental Hygiene, 113, 117 International Congress of Medicine, 199 International Congress on Mental Health, 125, 135 International Congress on Mental Hygiene, 117, 142, 169 internationalism, 1, 2, 4, 104 Isaacs, Susan (pseudonym: Ursula Wise), 148 Isserlin, Max, 52, 224 Itard, Jean Marc Gaspard, 37

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Jackson Kinderkrippe, 227 Jackson, John Hughlings, 114 Jackson, Mark, 7 Jackson, Milena, 231 James, William, 76, 113 Janet, Pierre, 112, 184, 199 Jeffries, 185 Jelliffe, Helena, 94 Jelliffe, Smith Ely, 4, 91, 93–104, 105nn14–15, 107n33 Jessen, Willers, 17 Jewish Board of Guardians, 230 Jewish Health Organisation, 221 Johns Hopkins University, 6, 115, 158, 160, 189, 201, 202, 205, 219 Johnstone, R. M., 211 Jolly, Friedrich, 21 Jones, Ernest, 95, 134, 184, 202–3, 218, 222, 225, 227

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index Jones, Mabel, 181 Jones, Robert Armstrong, 200 Journal of the American Medical Association, 92 Journal of Mental Science, 140, 143 Journal of Nervous and Mental Disease, 4, 93, 96–98, 103, 105n14, 106n27 Julius, Nikolaus Heinrich, 15 Jung, Carl Gustav, 95, 112, 165, 184, 199, 202 Kahn, Eugen, 6, 102, 156–57, 162–63, 165–73, 176n36 Kaiser Wilhelm Society (Kaiser-WilhelmGesellschaft), 5, 54–55, 61 Kaiser-Wilhelm-Institut für Psychiatrie, 99. See also German Psychiatric Research Institute Kapp, Yvonne, 223 Kardiner, Abram, 124 Kennedy, Alexander, 79 Kennoway Asylum, Scotland, 21 Kerlin, Isaac, 40 Kiel University, 209 kindergarten, 37–38 King Edward VII Hospital, 200, 201 Kipling, Rudyard, 72 Kirby, George, 59 Kirsch, James, 225 Klein, Melanie, 218, 222, 227 Kline, Wendy, 117 Klingenmünster Asylum, 17 Koch, Robert, 164 Kohler, Joanna (later Beekekenhof), 227 Kohon, Gregorio, 222 Kolb, Gustav, 115, 128n82 König, Karl Richard, 219, 231 König, Wilhelm Julius, 22 Kraepelin, Emil, 3–7, 26n10, 48–61, 62n7, 62n10, 63n21, 65nn48–49, 68–72, 93–94, 98–101, 114, 157, 159, 163–69, 177n40, 182, 186, 219 Kris, Ernst, 225, 227 Kris, Marianne, 225 Krupp von Bohlen und Halbach, Gustav, 56, 59

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249

Kut, Sara (later Rosenfeld), 227 Lady Chichester Hospital (LCH), 181– 85, 190–91 Laehr, Hans, 101 Laehr, Heinrich, 19 Laehr, Max, 182 Laing, Ronald D., 230 Lambert, Robert A., 211 Lancashire and Cheshire Society for the Permanent Care of the FeebleMinded, 32, 38 Lancet, 69, 205 Lane, Homer, 42 Lange, James, 73 Lange, Johann, 79 Langenhorn Asylum, Hamburg, 21, 23 Lapicque, 212 Last, S. L., 212 Laura Spelman Rockefeller Foundation, 120 Law for the Prevention of Offspring with Hereditary Disease, 74–75 Leubuscher, Rudolf, 16–17 Levin, Ernst, 230 Levinstein, Eduard, 21–22 Lewis, Aubrey, 4, 6, 74–80, 87n56, 88n65, 89n75, 221 Local Government Act, 143 Lockwood, Madeline, 204 Loeb, James, 56–57, 59 London Clinic of Psychoanalysis, 226 London County Council (LCC), 67, 68, 73, 79, 180, 187–89, 200 London County Council Act, 82n7, 180 London County Council’s Pathological Laboratory (CPL), 69–70, 73, 78–79, 87n64 London Psycho-Analytic Society, 184 London School of Economics, 120, 140, 147, 230, 231 London School of Medicine for Women, 181, 184 London University, 230 Long, Constance Ellen, 184–85 Lord, John Robert, 142–43, 153n33, 206 Lunacy Acts for England and Wales, 180

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250



index

Macalpine, Ida, 231 MacCalman, Douglas, 219 Maison de Santé, Berlin, 22 Malamud, William, 101 Manchester Kindergarten Association, 38 Manchester Northern Hospital, 226 Mann, Sidney, 73 Mapother, Edward, 70–80, 84n27, 88n73, 146, 186, 224 Marburg Institute of Hygiene, 79 Marburg, Otto, 100 Marinesco, Georges, 69 Martin, J. E., 72 Massachusetts General Hospital, 5 Maudsley Hospital, London, 4, 5, 67–81, 82n7, 143, 146, 180, 185–88, 191, 197, 202, 216n63, 219, 221, 223–24, 229–31 Maudsley, Henry, 106n24, 68, 71 May, Mark, 171 Mayer-Gross, William (Willy), 79–80, 89n75, 223–24, 228–29 May-Gross, Gertrude, 223 Mayo, William, 162 McCormick, Cyrus Hill, 56 McCormick, Stanley, 56 McCowan, 211 McDougall, William, 149 McKenna, Reginald, 198 McMillan, Margaret, 37 Mead, Margaret, 124 Medical Center of New York, 72 Medical Education, 168 Medical Research Council (MRC), 78, 209–13, 221, 223; Mental Disorders Committee, 74 Medical Women’s Federation, 184, 188 medicine as social science, 159–61, 172. See also Angell, James Rowland; Winternitz, Charles medicinische Lebensreform, Die, 16 medico-pedagogy, British, 7, 30–31, 33, 35–36, 41–42 Meduna, Ladislaus, 207–8 Mellanby, Edward, 213 Mendel, Emanuel, 19–21

Roelcke.indd Sec1:250

Mental After-Care Association, 135–36, 142 Mental Deficiency Act, 32, 135, 138, 139, 142, 222 Mental Health, 135 mental health care system; British, 13, 15, 17, 19, 22, 24, 179; German, 13, 22 Mental Hospitals Association, 201 Mental Hygiene, 135 mental hygiene movement, 1, 5; American, 7, 111, 113, 119, 123–24, 124, 133n73, 134, 157–58, 168, 204–5; British, 135, 137; international, 7, 135; and psychoanalysis, 121, 123, 131n49 Mental Treatment Act, 74, 143, 180, 183, 190, 191, 201, 222 Mental Welfare, 135 Metropolitan Asylums Board, 31 Metropolitan war hospital, 199. See also Cardiff City Mental Hospital Meyer, Adolf, 6, 7, 58–79, 84n27, 89n75, 91, 113–15, 142, 158–59, 169–70, 189, 199, 201–2, 205, 215n23, 210 Meyer, Alfred, 224 Meyer, Ludwig, 18 Michael, Pamela, 7 Michaelis, Moritz, 212–13, 221 Mill Hill Emergency Hospital, 224, 230 Millard, William, 38 Miller, Emanuel, 221 Miller, Hugh Crichton, 146 Milne, E. A., 74 Ministry of Health, 34, 183–84, 188, 201, 222, 226, 230 Ministry of Health Act, 201 Mommsen, Wolfgang J., 13 Montagu, George, 42 Montessori, Maria, 30–31, 37, 41–42, 227 Mott, Frederick, 67–73, 76, 81, 186 Moulson, 209 Mühlleitner, Elke, 222 Mühry, Adolf, 12 Müller, Friedrich, 99 Munich, Psychiatric Department and Clinic, 48, 52, 67–69, 156–57, 162–63, 182, 186, 200

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index Münsingen Mental Hospital, Berne, 207 Mussolini, Benito, 74 Mynatt, Margaret, 223 Nagelschmidt, 228 National Association for Mental Health, 135, 147 National Committee of Mental Hygiene (NCMH), 112–16, 119, 126, 126n1, 158–59, 190 National Council for Mental Hygiene, 113, 135–36, 142, 145, 190 National Froebel Union, 38 National Health Service, 150, 209, 229, 231 National Hospital, Queen Square, London, for the Relief and Cure of Diseases of the Nervous System, 5 National Institute for Medical Research, 210 National Insurance and Workmen’s Compensation, 144 National Research Council, 159 nationalism, 1, 3, 7, 59, 149 Neuburger, Max, 12 neurology, 21, 78, 98, 99, 102, 203, 223 neuropathology, 4, 79, 169 neurophysiology, 4, 73, 99 neuropsychiatry, 97, 99, 103 New England Journal of Medicine, 92 New Haven Dispensary, 160 New Haven Hospital, 160, 168 New York School of Social Work, 120 Newman, George, 34 Nissl, Franz, 70 Noll, Anni, 222 Noll, Richard, 184 North Wales Asylum, 200 North Wales Counties Mental Hospital, 208 Northfield Military Neurosis Centre, 228 North-Western Poor-Law Conference, 40 Nursery Schools Association, 227 O’Brien, D. P., 212–13 Ordnungspsychiatrie, 49 Osler, William, 202

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251

Parson’s Clinic, 146 Pasteur, Louis, 164 Pasteur Institute, 55, 79 patients, curable or incurable, 15–16, 18–19, 22, 197; male and female, 16, 21; ratio to nurses/medical staff, 16, 62n13, 208–8; rights of, 50; voluntary, 68, 82n7, 180, 182–85, 202 Paulsen, Friedrich, 160 Pear, Tom, 69 Pearce, Richard M., 60 Pelman, Carl Wilhelm, 19 Penn Hospital, Philadelphia, 72 Penrose, Lionel, 141, 211 Pestallozzi, Heinrich, 37 Pettenkofer, Max von, 12 philanthropy, 48–49, 56, 61, 136 Pierce, Charles Sanders, 113 Pines, Malcom, 203 Pinsent, Ellen, 32 Pioneer Health Centre/Peckham Experiment, 222 Plaut, Felix, 52, 59, 79, 89n75, 99, 102, 224 Plaut, Paul, 221 Plewa, Franz, 228 Pols, Hans, 5, 7 Post, Felix, 224, 230 Potts, Patricia, 35 Potts, William, 37–38 Pötzl, Otto, 207 Pratt, Georg K., 122–23 Prestwich County Mental Hospital, 228 Pritchard, David Gwyn, 30, 41 provincialism, 91, 98, 103, 107n28, 110n52 Psychiatrisch-Neurologische Wochenschrift, 94 psychiatry, academic, 156–57, 202, 229; American, 5, 7, 8, 102–4, 157, 172, 179, 183, 197, 207, 213; biological, 81, 146, 164–65, 172; British, 4, 7–8, 69, 74, 80, 151, 197, 199–200, 204–9, 215n38, 219, 221, 229, 231; child and adolescent, 5, 79, 119–20; dynamic, 99, 102, 113–15, 142; English, 67, 74, 78, 96; forensic, 163, 168; German,

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252



index

psychiatry, academic—(cont’d) 4, 24, 59, 61, 67, 74, 77, 91, 98, 113, 117, 146, 156–57, 163, 182, 205, 219; military, 117, 225; modern, 8, 16; Munich School of, 157, 163; research in the international dimension of, 2; Scottish, 7, 179; Welsh, 197–198, 202; as Wissenschaft, 16, 24–25, 103 Psychoanalytic Review, 94, 109n47 psychobiology, 79, 202 psychology, clinical, 79, 229; experimental, 57, 164, 169; industrial, 59; new, 146; occupational, 59; physiological, 70; social, 149, 203 psychopathology, 70–73, 78, 114, 116, 224 psychotherapy, 8, 72, 121, 123, 140, 143, 145–46, 149–50, 184–85, 190, 202–4, 218, 221–22, 225–26, 228 Quastel, Juda Hirsch, 210–13, 221 racial hygiene, 136 Racker, Efraim, 212, 213 Rank, Otto, 102 Rapp, Dean, 203 Rasemühle, Provincial Sanatorium for Nervous Patients, 182–83 Redlich, Frederick, 172 Rees, John Rawlings, 225, 226 refugees, medical, 80, 102, 212; and British psychiatry, 218–25, 228–31 Reichmayr, Johannes, 222 Reichsgesundheitsamt, 57 Revised Code, 31 Rhodes, John Milson, 39, 40 Ricciardi, Alice von Platen, 232n14 Richards, Esther, 189 Richter, Derek, 79, 221 Rickman, John, 222 Rivers, William H. R., 117 Robinson, George Canby, 160 Rockefeller, John, 56 Rockefeller Foundation, 4–6, 60, 74, 112, 116, 156–59, 162, 168; and: British psychiatry, 76–80, 146, 219, 223, 224, 230; fellowships, 5, 79; research work at Cardiff, 209–13, 221

Roelcke.indd Sec1:252

Rockefeller Institute for Medical Research, 205, 210 Roelcke, Volker, 6, 67, 95 Roemer, Hans, 115 Roller, Christian Friedrich Wilhelm, 15, 16 Rosanoff, Aaron, 116 Ross, Thomas, 71 Roth, Martin, 228 Rows, Ronald, 68–69 Royal Albert Asylum, Lancaster, 31, 37 Royal Commission on the Care and Control of the Feeble-Minded, 40, 138 Royal Commission on Lunacy and Mental Disorder, 183, 190, 200 Royal Earlswood Asylum, Surrey, 31 Royal Eastern Counties Institution, Colchester, 212 Royal Edinburgh Hospital, 207 Royal Medico-Psychological Association, 37, 206 Royal Society of Medicine, 76 Rüdin, Ernst, 7, 52, 53, 70, 99, 102, 117, 136, 139, 165 Ruggles, Arthur, 161, 162 Runwell Hospital, 226, 231 Salmon, Thomas W., 115, 117–18, 158–59 Sandlebridge Boarding Schools, 32, 34–36, 39, 40 Sano, Fritz, 68 Sargant, William, 72, 80, 148 Savage, George, 198 Schatz, Gottfried, 213 Schiff, Jakob Henry, 58, 60 Schilder, Paul, 96 Schlemm, Theodor, 17 Schmiedebach, Heinz-Peter, 3 Schneider, Carl, 78 Schneider, Kurt, 99 Scholberg, 199 Schorstein, Joseph, 230 Schurmann, Anneliese, 227 Schwarz, Ernst (Ernest), 208, 223 Schwarz, Hedy, 227

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index Schweizer Medizinische Wochenschrift, 100 Scottish Women’s Hospitals (SWH), 185 Séguin, Edouard, 37, 38, 40–42 Sex Disqualification (Removal) Act, 187 Shearer, Christine, 185 Sherrington, Charles S., 77 Shuttleworth, George, 33, 36–41 Sicher, Lydia, 228 Siemerling, Ernst, 22 Skottowe, Ian, 203–5 Slater, Eliot, 77–80, 221 Sloyd Movement, 42 Smith, M. Vernon, 15 Smith, William Clifford, 68 Smith School of Social work, Northampton, Massachusetts, 120 Smith, Grafton Elliot, 69 social work, 5, 119–20, 136, 142, 147, 151, 204, 229 Society of Analytical Psychology, 228 Society of German Alienists (Deutscher Verein für Psychiatrie), 55 Society for the Protection of Science and Learning, 79 Soloway, Richard, 76 Somaticism, 70 Sommer, Robert, 65n48, 113, 199 Spencer, Herbert, 113 Spielmeyer, Walter, 79, 102, 163 St. Elizabeth Hospital for the Insane, Washington, DC, 59, 119 St. Marylebone Institution, 189 St. Thomas Hospital, 180 Stahl, Ernst, 98 Stanford, R. V. 209–10 Starcross Asylum, Exeter, 31 Steedman, Carolyn, 30, 37, 41 Stein, Julius, 228 Stein, Leopold, 228 Steinthal, S. Alfred, 38 Stekel, Wilhelm, 96, 224 Stengel, Erwin, 225, 228, 229 Stephansfeld Asylum, 19 sterilization, 5, 7, 74–75, 116–17, 136, 139–41 Stern, Felix, 100

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253

Stern, Karl, 219 Stirling Distric Mental Hospital, Scotland, 185 Stoessiger, Hilda, 89n75 Strecker, Edward, 162 Strecker, Pullar, 207 Strich, Sabine, 230 Studies in Mental Inefficiency, 135 Swansea General Hospital, 204 Swansea Mental Hospital, 204, 205, 209 Tavistock Clinic, 79, 146, 180, 221–22, 225, 229 Temporary Registration Order, 222 Tennant, Thomas, 78 Tennenbaum, Michael, 212–13 Times, 188 therapy, group, 150; hydro-, 168; occupational, 16, 117, 168, 182, 205–7; persuasion, 145; physical, 168; psychodynamic, 184 Thomas, Alderman, 198 Thomas, W. Rees, 207–8 Thompson, Lloyd, 162, 167 Thomson, Mathew, 7 Timms, Edward, 227 treatment, shock, 103–4, 207–9, 223 Tredgold, Alfred, 32, 34–35, 38, 41, 141 Trinity College, Cambridge, 210 University of Chicago, 159, 160 University Clinic, Giessen, 206 University Neurological and Psychiatric Clinic, Vienna, 207 University of Wales, 202 urbanization, 1, 16 Vaihinger, Hans, 77 Wagner, Julius Jauregg von, 185 Wagner-Jauregg Clinic, Vienna, 225 Walker, Jane, 185 Wallentin, Lizzy (later Rolnick), 227 Walter, Grey, 79 Warneford and Park Hospitals, Oxford, 229 Wedgwood, Josiah, 180

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index

Weindling, Paul Julian, 6, 7 Weissmann, Emerich, 228 Weizsäcker, Viktor von, 101 Welch, William Henry, 160, 162 Welsh Board of Health, 201 Welsh College of Medicine, Cardiff, 202, 212 Welsh Consultative Committee, 201 West End Hospital, 185 West Sussex Child Guidance Service, 227 Westphal, Carl, 183 Westwood, Louise, 5, 6 White, William Alanson, 94–96, 119 Wilbur, Hervey, 40 Williams, Frankwood E., 124 Wilson, Isabel, 206–9 Winslow, Charles E. A., 160 Winslow, L. S. Forbes, 180 Winternitz, Charles, 157, 159, 160–63, 167, 171–72

Roelcke.indd Sec1:254

Wissenschaft, 14, 16, 24–25, 26n9 Wittkower, Erich (Eric), 78–80, 89n75, 229 Wolff, Charlotte, 219 World Federation of Mental Health, 125 Wundt, Wilhelm, 160 Wuth, Otto, 186 Yale University, 156–57, 159, 161–63, 166–73, 213; Department of Psychiatry and Mental Hygiene, 6, 156–57, 159 Yellowlees, Henry, 148 Yerkes, Robert, 171 Zeitschrift für die gesamte Neurologie und Psychiatrie, 101 Ziehen, Theodor, 93, 182 Zimmermann, Harry, 163, 167 Zoological Society, 219 Zucker, Konrad, 78, 89n75

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Edited by

Contributors: John C. Burnham, Eric J. Engstrom, Rhodri Hayward, Mark Jackson, Pamela Michael, Hans Pols, Volker Roelcke, Heinz-Peter Schmiedebach, Mathew Thomson, Paul J. Weindling, Louise Westwood

—Andreas Daum, author of Kennedy in Berlin (2008) and Popularizing Science in the Nineteenth Century (German, 2002)

“This is a pioneering effort to advance the historiography of one significant branch of medicine, psychiatry, beyond perspectives limited to any single nation. . . . The volume has the potential to affect both the history of medicine in general and the historiography of psychiatry in particular.” —Mitchell Ash, coeditor of Forced Migration and Scientifi c Change: Émigré German-Speaking Scientists and Scholars after 1933 (1996) Cover illustrations: John Barnett /4 Eyes Design and Shutterstock.

668 Mt. Hope Avenue, Rochester, NY 14620–2731, USA P.O. Box 9, Woodbridge, Suffolk IP12 3DF, UK www.urpress.com

International Relations in Psychiatry

Britain, Germany, and the United States to World War II

“The contributors to this volume demonstrate convincingly that any modern history of knowledge—and more specifically that of scientific disciplines and medicine as practiced in hospitals and asylums—needs to take forms of transnational communication into account.”

International Relations in Psychiatry

The decades around 1900 were crucial in the evolution of modern medical and social sciences, and in the formation of various national health services systems. The modern fields of psychiatry and mental health care are located at the intersection of these spheres. There emerged concepts, practices, and institutions that marked responses to challenges posed by urbanization, industrialization, and the formation of the nationstate. These psychiatric responses were locally distinctive, and yet at the same time established influential models with an international impact. In spite of rising nationalism in Europe, the intellectual, institutional, and material resources that emerged in the various local and national contexts were rapidly observed to have had an impact beyond any national boundaries. In numerous ways, innovations were adopted and refashioned for the needs and purposes of new national and local systems. International Relations in Psychiatry: Britain, Germany, and the United States to World War II brings together hitherto separate approaches from the social, political, and cultural history of medicine and health care and argues that modern psychiatry developed in a constant, though not always continuous, transfer of ideas, perceptions, and experts across national borders.

Roelcke Weindling Westwood

Britain, Germany, and the United States to World War II Edited by Volker Roelcke ° Paul J. Weindling ° Louise Westwood